Clinical evaluation of the Er:YAG laser in combination with an enamel matrix protein derivative for the treatment of intrabony periodontal defects: a pilot study

OBJECTIVES: The aim of the present study was to compare the combination therapy of deep intrabony periodontal defects using an Er:YAG laser (ERL) and enamel matrix protein derivative (EMD) to scaling and root planing+ ethylenediaminetetraacetic acid (EDTA)+EMD. MATERIAL AND METHODS: Twenty-two patients with chronic periodontitis, each of whom displayed 1 intrabony defect, were randomly treated with access flap surgery and defect debridement with an Er:YAG (160 mJ/pulse, 10 Hz) plus EMD (test) or with access flap surgery followed by scaling and root planing (SRP) with hand instruments plus EDTA and EMD (control). The following clinical parameters were recorded at baseline and at 6 months: plaque index, gingival index, bleeding on probing (BOP), probing depth (PD), gingival recession, and clinical attachment level (CAL). No differences in any of the investigated parameters were observed at baseline between the two groups. RESULTS: Healing was uneventful in all patients. At 6 months after therapy, the sites treated with ERL and EMD showed a reduction in mean PD from 8.6 +/- 1.2 mm to 4.6 +/- 0.8 mm and a change in mean CAL from 10.7 +/- 1.3 mm to 7.5 +/- 1.4 mm (p < 0.001). In the group treated with SRP+EDTA+EMD, the mean PD was reduced from 8.1 +/- 0.8 mm to 4.0 +/- 0.5 mm and the mean CAL changed from 10.4 +/- 1.1 mm to 7.1 +/- 1.2 mm (p < 0.001). No statistically significant differences in any of the investigated parameters were observed between the test and control group. CONCLUSION: Within the limits of the present study, it may be concluded that both therapies led to short-term improvements of the investigated clinical parameters, and the combination of ERL and EMD does not seem to improve the clinical outcome of the therapy additionally compared to SRP+EDTA+EMD.     

EDTA gel root conditioning: lack of effect on clinical and radiographic outcomes of intrabony defect treatment with enamel matrix derivative

BACKGROUND: The adjunctive use of enamel matrix derivative (EMD) in the surgical therapy of intrabony defects results in improved outcomes compared to surgical debridement alone. However, the role of EDTA root conditioning in EMD therapy has not been investigated. The purpose of this study was to compare the 12-month outcomes of EMD application with and without EDTA root conditioning in intrabony defect surgical therapy. METHODS: Twenty-eight chronic periodontitis patients, each contributing a 2- or 3-wall intrabony defect (> or = 4 mm deep and > or = 2 mm wide), participated. Patients consecutively received surgical treatment with either EMD alone (first 13 patients) or EMD + EDTA (subsequent 15 patients). Probing depth (PD), clinical attachment level (CAL), and gingival margin position, i.e., recession (REC) were the clinical parameters recorded. Recorded radiographic parameters were the distances from 1) cemento-enamel junction to bone crest (CEJ to BC), 2) CEJ to base of the defect (CEJ to BD), and 3) BC to BD. RESULTS: Intragroup analysis showed that both EMD alone and EMD + EDTA led to significant PD reduction, CAL gain, and REC increase 1 year postoperatively. Both groups had >60% mean radiographic defect resolution (change in BC to BD). None of the recorded parameters were significantly different between the two groups, either at baseline or postoperatively. CONCLUSIONS: These results suggest that clinical and radiographic outcomes of intrabony defect EMD therapy do not depend on the use of EDTA gel root conditioning. The potential contribution of EDTA gel root conditioning to the histological outcomes reported with EMD therapy remains to be determined.     

Five-year results following treatment of intrabony defects with enamel matrix proteins and guided tissue regeneration

BACKGROUND: Treatment with enamel matrix proteins (EMD) or guided tissue regeneration (GTR) has been shown to enhance periodontal regeneration. However, until now there are limited data on the long-term results following these treatment modalities. Aim: The aim of the present clinical study was to present the 5-year results following treatment of intrabony defects with EMD, GTR, combination of EMD and GTR, and open flap debridement (OFD). MATERIAL AND METHODS: Forty-two patients, each of whom displayed one intrabony defect of a probing depth of at least 6 mm, were randomly treated with one of the four treatment modalities. The following parameters were evaluated prior to surgery, at 1 year and at 5 years after: plaque index, gingival index, bleeding on probing, probing pocket depth (PPD), gingival recession, and clinical attachment level (CAL). No statistically significant differences in any of the parameters were observed at baseline between the four groups. RESULTS: The sites treated with EMD demonstrated a mean CAL gain of 3.4+/-1.1 mm (p<0.001) and of 2.9+/-1.6 mm (p<0.001) at 1 and 5 years, respectively. The sites treated with GTR showed a mean CAL gain of 3.2+/-0.8 (p<0.001) at 1 year and of 2.7+/-0.9 mm (p<0.001) at 5 years. The mean CAL gain at sites treated with EMD+GTR was 3.0+/-1.0 mm (p<0.001) and 2.6+/-0.7 mm (p<0.001) at 1 and 5 years, respectively. The sites treated with OFD demonstrated a mean CAL gain of 1.6+/-1.0 mm (p<0.001) at 1 year and 1.3+/-1.2 mm (p<0.001) at 5 years. At 1 year, the only statistically significant difference between the four different treatments was found in terms of PPD reduction and CAL gain between EMD and OFD (p<0.05). However, at 5 years there were no statistically significant differences in any of the investigated parameters between the four different treatments. CONCLUSION: Within the limits of the present study, it may be concluded that the short-term clinical results following treatment with EMD, GTR, EMD+GTR, and OFD can be maintained over a period of 5 years.     

Clinical evaluation of an enamel matrix protein derivative combined with either a natural bone mineral or beta-tricalcium phosphate

BACKGROUND: The purpose of the present study was to compare the healing of deep intrabony defects following treatment with an enamel matrix protein derivative (EMD) combined with either a natural bone mineral (NBM) or beta-tricalcium phosphate (beta-TCP). METHODS: Twenty-four patients with advanced periodontal disease, each of whom displayed one intrabony defect, were randomly treated with a combination of either EMD + NBM or EMD + beta-TCP. Clinical evaluation was performed at baseline and 1 year following therapy. RESULTS: No differences in any of the investigated parameters were observed at baseline between the two groups. Healing was uneventful in all patients. At 1 year after therapy, the sites treated with EMD + NBM showed a reduction in mean probing depth (PD) from 7.9 +/- 1.0 mm to 3.2 +/- 0.6 mm and a change in mean clinical attachment level (CAL) from 8.8 +/- 1.1 mm to 4.5 +/- 0.6 mm (P < 0.001). In the group treated with EMD + beta-TCP, the mean PD was reduced from 7.8 +/- 1.2 mm to 3.2 +/- 0.9 mm, and the mean CAL changed from 8.8 +/- 1.2 mm to 4.7 +/- 1.2 mm (P < 0.001). In both groups, all sites gained at least 3 mm of CAL. CAL gains of 4 or 5 mm were measured in the majority of the cases (75%), irrespective of treatment modality. No statistically significant differences in terms of PD reductions and CAL gains were observed between the two groups. CONCLUSION: Within the limits of the present study, both therapies resulted in significant PD reductions and CAL gains 1 year after surgery.     

Enamel Matrix Derivative,Alone or Associated With a Synthetic Bone Substitute,in the Treatment of 1‐ to 2‐Wall Periodontal Defects

Background: In this study, we compare the effects of enamel matrix derivative (EMD) associated with a hydroxyapatite and β‐tricalcium phosphate (HA/β‐TCP) implant to EMD alone and to open‐flap debridement (OFD) when surgically treating 1‐ to 2‐wall intrabony defects. Methods: Thirty‐four patients, exhibiting ≥3 intraosseous defects in different quadrants, were each treated by OFD, EMD, or EMD + HA/β‐TCP in each defect. At baseline and 12 and 24 months, a complete clinical and radiographic examination was done. Pre‐therapy and post‐therapy clinical (probing depth [PD], clinical attachment level [CAL], and gingival recession [GR]) and radiographic (defect bone level [DBL] and radiographic bone gain [RBG]) parameters for the different treatments were compared. Results: After 12 and 24 months, almost all the clinical and radiographic parameters showed significant changes from baseline within each group (P <0.001). Differences in PD, CAL, and DBL scores were also seen among the three groups at the 12‐ and 24‐month visits (P <0.001). At 12 and 24 months after treatment, the EMD + HA/β‐TCP group showed significantly greater PD reduction (4.00 ± 0.42 mm; 4.25 ± 0.63 mm), CAL gain (3.47 ± 0.65 mm; 3.63 ± 0.91 mm), and RBG (3.17 ± 0.69 mm; 3.35 ± 0.80 mm) and less GR increase (0.56 ± 0.37 mm; 0.63 ± 0.42 mm) compared with the OFD and EMD groups (P <0.05). Conclusion: Our data support the hypothesis that the adjunct of an HA/β‐TCP composite implant with EMD may improve the clinical and radiographic outcomes of the surgical treatment of unfavorable intrabony defects.     

The effect of postsurgical administration of a selective cyclo-oxygenase-2 inhibitor on the healing of intrabony defects following treatment with enamel matrix proteins

Regenerative treatment with enamel matrix proteins (EMD) has been shown to promote regeneration in intrabony periodontal defects. However, up to now various postoperative regimens such as the routine administration of nonsteroidal anti-inflammatory drugs (NSAIDs) were often used in combination with enamel matrix proteins. Therefore, it cannot be excluded that the results might have been influenced by the effect of the postoperative medication. The aim of this randomized, controlled, blinded, clinical investigation was to determine the effect of postsurgical administration of a selective cyclo-oxygenase-2 inhibitor on the healing of intrabony periodontal defects following regenerative periodontal surgery with EMD. Twenty two patients, each of whom exhibited one deep intrabony defect, were randomly treated with either EMD plus a selective cyclo-oxygenase-2 (COX-2) inhibitor (test) or with EMD alone (control). The postoperative regimen consisted of oral administration of 12.5 mg rofecoxib twice daily for 14 days. The following parameters were recorded at baseline and at 6 months by the same calibrated and blinded investigator: plaque index (Pl), gingival index (GI), bleeding on probing (BOP), pocket depth (PD), gingival recession (GR), and clinical attachment level (CAL). Power analysis to determine superiority of the anti-inflammatory treatment showed that the available sample size would yield 70% power to detect a 1 mm difference. No statistical significant differences in any of the investigated parameters between the two groups were observed at baseline. The results show that, in the test group, mean PD decreased from 8.7+/-1.4 mm to 4.7+/-2.0 mm (P<0.001) and mean CAL from 9.7+/-2.0 mm to 6.5+/-2.1 mm (P<0.001). In the control group, mean PD decreased from 8.6+/-1.6 mm to 4.7+/-1.8 mm (P<0.001) and mean CAL from 9.5+/-1.6 mm to 6.5+/-2.2 mm (P<0.001). There were no significant differences between the two groups in any of the investigated parameters. Within the limits of the present study, it can be concluded that the systemic administration of a selective COX-2 inhibitor following regenerative periodontal surgery with EMD did not result in additional clinical improvements when compared to treatment with EMD alone.     

Treatment of intrabony defects with enamel matrix proteins or bioabsorbable membranes. A 4-year follow-up split-mouth study.

BACKGROUND: Treatment with enamel matrix proteins (EMD) and guided tissue regeneration (GTR) with bioabsorbable membranes has been shown to promote periodontal regeneration; however, until now, there were only limited data on the long-term clinical results following these regenerative techniques. Therefore, the aim of the present study was to present the 4-year results following treatment of intrabony defects with EMD or guided tissue regeneration (GTR). METHODS: Twelve patients, each displaying one pair of intrabony defects located contralaterally in the same jaw, were randomly treated with EMD or with GTR by means of bioabsorbable membranes. The following clinical parameters were evaluated at baseline, at 1 year, and at 4 years after treatment: plaque index (P1), gingival index (G1), bleeding on probing (BOP), probing depth (PD), gingival recession (GR), and clinical attachment level (CAL). The primary outcome variable was CAL. No statistically significant differences between the groups were found at baseline. Power analysis to determine superiority of EMD treatment showed that the available sample size would yield 70% power to detect a 1 mm difference. RESULTS: The sites treated with EMD demonstrated mean CAL change from 9.8 +/- 2.0 mm to 6.4 +/- 1.6 mm (P<0.001) and to 6.8 +/- 1.8 mm (P<0.001) at 1 and 4 years, respectively. No statistically significant differences were found between the CAL mean at 1 and 4 years postoperatively. The sites treated with GTR showed a mean CAL change from 9.8 +/- 2.3 mm to 6.6 +/- 1.7 mm (P<0.001) at 1 year and to 6.9 +/- 1.8 mm (P<0.001) at 4 years. The CAL change between I and 4 years did not present statistically significant differences. No statistically significant differences in any of the investigated parameters were observed at 1 and 4 years between the treatment groups. CONCLUSIONS: It was concluded that the CAL gain obtained following treatment with EMD or GTR can be maintained over a 4-year period.     

Effect of platelet-rich plasma on the healing of intrabony defects treated with an enamel matrix protein derivative and a natural bone mineral

Background: Regenerative periodontal surgery utilizing a combination of an enamel matrix protein derivative (EMD) and a natural bone mineral (NBM) and platelet‐rich plasma (PRP) has been shown to enhance the outcomes of regenerative surgery significantly. At present, it is unknown whether root conditioning with EMD, followed by defect fill with a combination of NBM+PRP may additionally enhance the clinical results obtained with EMD+NBM. Aim: To compare clinically the treatment of deep intrabony defects with either EMD+NBM+PRP or EMD+NBM. Material and Methods: Twenty‐six patients suffering from advanced chronic periodontitis, and each of whom displayed one advanced intrabony defect were randomly treated with either EMD+NBM+PRP (test) or EMD+NBM (control). The following clinical parameters were evaluated at baseline and at 1 year after treatment: plaque index (PI), gingival index (GI), bleeding on probing (BOP), probing depth (PD), gingival recession (GR) and clinical attachment level (CAL). The primary outcome variable was CAL. Results: Healing was uneventful in all patients. At 1 year after therapy, the test sites showed a reduction in mean PD from 8.8±1.9 mm to 3.1±0.9 mm ( p<0.001) and a change in mean CAL from 10.8±2.0 mm to 6.0±1.5 mm ( p<0.001). In the control group the mean PD was reduced from 8.8±2.0 mm to 2.8±1.6 mm ( p<0.001) and the mean CAL changed from 10.5±1.6 mm to 5.5±1.4 mm ( p<0.001). CAL gains of 4 mm were measured in 77% (i.e. in 10 out of 13 defects) of the cases treated with EMD+NBM+PRP and in 100% (i.e. in all 13 defects) treated with EMD+NBM. No statistically significant differences in any of the investigated parameters were observed between the two groups. Conclusions: Within its limits, the present study has shown that (i) 1 year after regenerative surgery, both treatments resulted in statistically significant PD reductions and CAL gains and (ii) the use of PRP failed to enhance the results obtained with EMD+NBM.     

Effect of platelet-rich plasma on the healing of intrabony defects treated with an anorganic bovine bone mineral and expanded polytetrafluoroethylene membranes

BACKGROUND: Regenerative periodontal therapy with a combination of platelet-rich plasma (PRP) + an anorganic bovine bone mineral (ABBM) + guided tissue regeneration (GTR) has been shown to result in significantly higher probing depth reductions and clinical attachment level gains compared to treatment with open flap debridement (OFD) alone, ABBM alone, or GTR alone. However, there are no data evaluating to what extent the use of PRP may additionally enhance the clinical outcome of the therapy compared to treatment with ABBM + GTR. This study aimed to clinically evaluate the effect of PRP on the healing of deep intrabony defects treated with ABBM and GTR by means of a non-resorbable expanded polytetrafluoroethylene (ePTFE) membrane. METHODS: Twenty-four patients with advanced chronic periodontal disease and displaying one intrabony defect were randomly treated with a combination of either PRP + ABBM + GTR or ABBM + GTR. The following clinical parameters were evaluated at baseline and at 1 year after treatment: plaque index (PI), gingival index (GI), bleeding on probing (BOP), probing depth (PD), gingival recession (GR), and clinical attachment level (CAL). The primary outcome variable was CAL. RESULTS: No differences in any of the studied parameters were observed at baseline between the two groups. Healing was uneventful in all patients. At 1 year after therapy, the sites treated with PRP + ABBM + GTR showed a reduction in mean PD from 8.6 +/- 1.7 mm to 3.1 +/- 1.3 mm (P <0.001) and a change in mean CAL from 10.3 +/- 1.4 mm to 5.7 +/- 1.6 mm (P <0.001). In the group treated with ABBM + GTR, mean PD was reduced from 8.8 +/- 1.7 mm to 3.1 +/- 1.0 mm (P <0.001), and the mean CAL changed from 10.4 +/- 2.6 mm to 5.9 +/- 1.8 mm (P <0.001). In both groups, all sites gained > or =3 mm of CAL. CAL gains > or =4 mm were measured in 83% (i.e., in 10 of 12 defects) of the cases treated with PRP + ABBM + GTR and in 92% (i.e., in 11 of 12 defects) treated with ABBM + GTR. No statistically significant differences in any of the studied parameters were observed between the two groups at 1-year reevaluation. CONCLUSION: Within its limits, the present study has shown that, at 1 year after regenerative therapy in periodontal intrabony defects, optimal clinical results were obtained with ABBM + GTR with a non-resorbable barrier, with or without the addition of PRP.     

Healing of human intrabony defects following regenerative periodontal therapy with an enamel matrix protein derivative alone or combined with a bioactive glass. A controlled clinical study

AIM: The purpose of the present study was to compare clinically the treatment of deep intrabony defects with a combination of an enamel matrix protein derivative (EMD) and a bioactive glass (BG) to EMD alone. METHODS: Thirty patients (16 females and 14 males) suffering from advanced marginal periodontitis were included in this prospective, controlled parallel design multicenter study. In each of the patients, one intrabony defect was randomly treated with either EMD+BG (test) or with EMD alone (control). Clinical measurements were recorded at baseline and at 1 year following therapy. RESULTS: No differences in any of the investigated parameters were observed at baseline between the two groups. Healing was uneventful in all patients. At 1 year after therapy, the test group showed a reduction in mean probing depth (PD) from 8.5+/-1.1 to 4.4+/-1.2 mm (p<0.001) and a change in mean clinical attachment level (CAL) from 10.4+/-1.5 to 7.1+/-1.5 mm (p<0.0001). In the control group, the mean PD was reduced from 8.5+/-1.5 to 4.0+/-1.6 mm (p<0.001) and the mean CAL changed from 10.2+/-2.1 to 6.3+/-2.2 mm (p<0.01). In the test group, 12 sites (80%) gained at least 3 mm or more of CAL, whereas in the control group a CAL gain of 3 mm or more was measured at 13 sites (87%). No statistically significant differences in terms of PD reduction and CAL gain were found between the test and the control treatment. CONCLUSIONS: Within the limits of the present study it can be concluded that: (i) at 1 year after surgery, both therapies resulted in significant PD reductions and CAL gains, and (ii) the combination of EMD+BG does not seem to additionally improve the clinical results.     

The effect of postsurgical antibiotics on the healing of intrabony defects following treatment with enamel matrix proteins

BACKGROUND: Regenerative treatment with enamel matrix proteins has been shown to promote healing in intrabony defects. However, up to now various postoperative antibiotic regimens have been used in combination with enamel matrix proteins and therefore it cannot be excluded that the results may also be attributable to the effect of the antibiotic treatment. The aim of this randomized, controlled, blinded, clinical investigation was to determine the effect of postsurgical administration of antibiotics on the healing of intrabony periodontal defects treated with enamel matrix proteins. METHODS: Thirty-four patients each of whom exhibited one deep intrabony defect were randomly treated with either enamel matrix proteins plus antibiotics (test: EMD + AB) or with enamel matrix proteins alone (control: EMD). The antibiotic regimen consisted of a combination of 3 x 375 mg amoxicillin and 3 x 250 mg metronidazole daily for 7 days. The following parameters were recorded at baseline and at 1 year by the same calibrated and blinded investigator: plaque index (PI), gingival index (GI), bleeding on probing (BOP), probing depth (PD), gingival recession (GR), and clinical attachment level (CAL). Power analysis to determine superiority of antibiotic treatment showed that the available sample size would yield 85% power to detect a 1 mm difference. RESULTS: No statistically significant differences in any of the investigated parameters between the 2 groups were observed at baseline. No serious adverse events such as allergic reactions or abscesses after any of the treatments were observed during the entire study period. The results have shown that in the EMD + AB group the PD decreased from 9.1 +/- 1.5 mm to 4.5 +/- 1.1 mm (P<0.0001) and the CAL changed from 11.0 +/- 1.6 mm to 7.5 +/- 1.4 mm (P<0.0001). In the EMD group the PD decreased from 9.0 +/- 1.7 mm to 4.3 +/- 1.7 mm (P <0.0001) and the CAL changed from 10.6 +/- 1.6 mm to 7.3 +/- 1.5 mm (P <0.0001). There were no significant differences in any of the investigated parameters between the 2 groups. CONCLUSIONS: It can be concluded that the systemic administration of amoxicillin and metronidazole adjacent to the use of EMD for the surgical treatment of intrabony periodontal defects does not produce statistically superior PD reduction and CAL gain when compared to treatment with EMD alone. Hence, the present results do not support the routine administration of amoxicillin and metronidazole following regenerative treatment with EMD.     

Effect of platelet-rich plasma on the healing of intrabony defects treated with Beta tricalcium phosphate and expanded polytetrafluoroethylene membranes

BACKGROUND: Regenerative periodontal therapy using platelet-rich plasma (PRP) and different types of bone substitutes with or without guided tissue regeneration (GTR) has been proposed as a modality to enhance the outcome of regenerative surgery. However, there are limited data from controlled clinical studies evaluating the effect of PRP on the healing of deep intrabony defects treated with a combination of bone substitutes and GTR. The aim of this study was to clinically evaluate the effect of PRP on the healing of deep intrabony defects treated with beta tricalcium phosphate (beta-TCP) and GTR by means of a non-bioresorbable expanded polytetrafluoroethylene membrane. METHODS: Twenty-eight subjects with advanced chronic periodontal disease and displaying one intrabony defect were treated randomly with a combination of PRP + beta-TCP + GTR or beta-TCP + GTR. Plaque index, gingival index, bleeding on probing, probing depth (PD), gingival recession, and clinical attachment level (CAL) were evaluated at baseline and at 1 year after treatment. CAL was the primary outcome variable. RESULTS: No differences in any of the investigated parameters were observed at baseline between the two groups. Healing was uneventful in all subjects. At 1 year after therapy, the sites treated with PRP + beta-TCP + GTR showed a reduction in mean PD from 9.1 +/- 0.6 mm to 3.3 +/- 0.5 mm (P <0.001) and a change in mean CAL from 10.1 +/- 1.3 mm to 5.7 +/- 1.1 mm (P <0.001). In the group treated with beta-TCP + GTR, mean PD was reduced from 9.0 +/- 0.8 mm to 3.6 +/- 0.9 mm (P <0.001), and the mean CAL changed from 9.9 +/- 1.0 mm to 5.9 +/- 1.2 mm (P <0.001). In both groups, all sites gained > or =3 mm of CAL. CAL gains > or =4 mm were noted in 86% (12 of 14 defects) of the cases treated with PRP + beta-TCP + GTR and in 79% (11 of 14 defects) of those treated with beta-TCP + GTR. No statistically significant differences in any of the investigated parameters were observed between the two groups at the 1-year reevaluation. CONCLUSION: At 1 year after surgery, both therapies resulted in significant PD reductions and CAL gains.     

Nine-year results following treatment of intrabony periodontal defects with an enamel matrix derivative: report of 26 cases

Treatment of intrabony periodontal defects with an enamel matrix derivative (EMD) has been demonstrated, in the short term, to result in periodontal regeneration and to significantly improve clinical parameters such as probing depth (PD) and clinical attachment level (CAL). The present study evaluated deep intrabony defect sites at 9 years after treatment with EMD. Twenty-one patients with a total of 26 deep intrabony defects with PD > or = 6 mm and intrabony depth > or = 3 mm, as identified by probing and radiographs, were consecutively treated with EMD. PD, recession of the gingival margin (GR), and CAL were evaluated prior to treatment and at 1 and 9 years after treatment. At 1 year, mean PD was significantly reduced. At 9 years, mean PD was statistically significantly increased versus the 1-year results but still significantly improved versus baseline. After I year, mean GR had increased significantly; at 9 years, measurements showed statistically significant improvements compared to the 1-year results and baseline. The mean CAL changed from 10.0 +/- 2.3 mm at baseline to 6.8 +/- 2.3 mm at 1 year and to 7.0 +/- 1.9 mm at 9 years. No treated teeth were lost during the observation period. The clinical improvements obtained following treatment with EMD can be maintained over a period of 9 years.     

Five-year results of a prospective, randomized, controlled study evaluating treatment of intra-bony defects with a natural bone mineral and GTR

BACKGROUND: Treatment with a natural bone mineral (NBM) and a guided tissue regeneration (GTR) has been shown to promote periodontal regeneration. However, until now there are only very limited data on the long-term clinical results following this regenerative technique. AIM: To present the 5-year results of a prospective, randomized, controlled clinical study evaluating the treatment of deep intra-bony defects either with open flap debridement (OFD) and a combination of an NBM and GTR (test) or OFD alone (control). METHODS: Nineteen patients diagnosed with advanced chronic periodontitis, and each of whom displayed one intra-bony defect, received randomly the test or the control treatment. Results were evaluated at baseline, at 1 and at 5 years following therapy. RESULTS: No statistically significant differences in any of the investigated parameters were observed at baseline between the two groups. At 1 year after therapy, the test group showed a reduction in mean probing depth (PD) from 9.1+/-1.1 to 3.7+/-0.8 mm (p<0.001) and a change in mean clinical attachment level (CAL) from 10.4+/-1.3 to 6.4+/-1.2 mm (p<0.001). At 5 years, mean PD and CAL measured 4.3+/-0.8 and 6.7+/-1.6 mm, respectively. At 5 years, both PD and CAL were statistically significantly improved compared with baseline (p<0.001) without statistically significant differences between the 1- and 5-year results. In the control group, mean PD was reduced from 8.9+/-1.3 to 4.9+/-1.2 mm (p<0.001) and mean CAL changed from 10.6+/-1.4 to 8.8+/-1.5 mm (p<0.01). At 5 years, mean PD and CAL measured 5.6+/-1.1 and 9.1+/-1.3 mm, respectively, and were still statistically significantly improved compared with baseline (p<0.01). No statistically significant differences were found between the 1- and 5-year results. The test treatment, at both 1 and 5 years, yielded statistically significantly higher CAL gains than the control one (p<0.01). Compared with baseline, at 5 years a CAL gain of > or =3 mm was found in nine defects (90%) of the test group but in none of the defects treated with OFD alone. CONCLUSIONS: It was concluded that (i) treatment of intra-bony defects with OFD+NBM+GTR may result in significantly higher CAL gains than treatment with OFD, and (ii) the clinical results obtained after both treatments can be maintained over a period of 5 years.     

Clinical Outcomes Following Regenerative Therapy of Non‐Contained Intrabony Defects Using a Deproteinized Bovine Bone Mineral Combined With Either Enamel Matrix Derivative or Collagen Membrane

Background: The purpose of this study is to compare clinical outcomes in the treatment of deep non‐contained intrabony defects (i.e., with ≥70% 1‐wall component and a residual 2‐ to 3‐wall component in the most apical part) using deproteinized bovine bone mineral (DBBM) combined with either enamel matrix protein derivative (EMD) or collagen membrane (CM). Methods: Forty patients with multiple intrabony defects were enrolled. Only one non‐contained defect per patient with an intrabony depth ≥3 mm located in the interproximal area of single‐ and multirooted teeth was randomly assigned to the treatment with either EMD + DBBM (test: n = 20) or CM + DBBM (control: n = 20). At baseline and after 12 months, clinical parameters including probing depth (PD) and clinical attachment level (CAL) were recorded. The primary outcome variable was the change in CAL between baseline and 12 months. Results: At baseline, the intrabony component of the defects amounted to 6.1 ± 1.9 mm for EMD + DBBM and 6.0 ± 1.9 mm for CM + DBBM sites (P = 0.81). The mean CAL gain at sites treated with EMD + DBBM was not statistically significantly different (P = 0.82) compared with CM + DBBM (3.8 ± 1.5 versus 3.7 ± 1.2 mm). No statistically significant difference (P = 0.62) was observed comparing the frequency of CAL gain ≥4 mm between EMD + DBBM (60%) and CM + DBBM (50%) or comparing the frequency of residual PD ≥6 mm between EMD + DBBM (5%) and CM + DBBM (15%) (P = 0.21). Conclusion: Within the limitations of the present study, regenerative therapy using either EMD + DBBM or CM + DBBM yielded comparable clinical outcomes in deep non‐contained intrabony defects after 12 months.     

Coronally advanced flap for the treatment of buccal gingival recessions with and without enamel matrix derivative. A split-mouth study

BACKGROUND: The coronally advanced flap (CAF) is a predictable method for achieving root coverage in buccal gingival recessions. The use of enamel matrix derivative (EMD) has already been tested in treating intrabony defects. No clinical comparative study has been published evaluating the CAF in combination with EMD in treating buccal gingival recessions. METHODS: This split-mouth study was performed to assess the efficacy of EMD to improve the results of a root coverage procedure. Fourteen pairs of Miller Class I and II bilateral comparable defects were selected in 12 patients. In each patient, one site was randomly assigned to the test group and the contralateral site to the control group. The treatment consisted of a CAF procedure with (test) or without (control) EMD. Gingival recession (REC), clinical attachment level (CAL), probing depth (PD), and extension of keratinized tissue (KT) were recorded at baseline and 6 months postsurgery. RESULTS: The average initial REC was 3.71 mm (SD +/- 1.68) for the test group, and 3.50 mm (SD +/- 1.56) for the control group. The 2 groups were statistically homogeneous. The mean root coverage was 3.36 mm (SD +/- 1.55), corresponding to a value of 91.2% for the test group, and 2.71 mm (SD +/- 1.20), equal to 80.9% for the control group. The differences between the 2 groups were not statistically significant. The mean CAL gain was 3.57 mm (SD +/- 1.55) for the test group and 2.79 mm (SD +/- 1.19) for the control group. No changes of PD and KT were found. CONCLUSIONS: This study suggests that EMD does not seem to significantly improve the clinical outcomes of gingival recession treated by means of CAF, even though the test group showed slightly better results in terms of root coverage and CAL. Further studies with a larger number of teeth and higher statistical power are needed to support this conclusion.     

Clinical evaluation of demineralized freeze-dried bone allograft and enamel matrix derivative versus enamel matrix derivative alone for the treatment of periodontal osseous defects in humans

BACKGROUND: A recent study suggests that the addition of enamel matrix derivative to demineralized freeze-dried bone allograft may enhance osseoinduction. The purpose of this study was to evaluate the use of demineralized freeze-dried bone allograft (DFDBA) in combination with enamel matrix derivative (EMD + DFDBA) compared to enamel matrix derivative (EMD) alone in the treatment of human intrabony periodontal defects. METHODS: Forty patients with a total of 67 sites (intrabony defect > or = 3 mm deep) were selected to participate in this single-masked, parallel design, randomized, controlled clinical trial. Each subject received either EMD alone (34 sites) or in combination with DFDBA (33 sites). Soft tissue measurements included probing depth (PD), clinical attachment level (CAL), and recession. Hard tissue measurements included defect depth, alveolar crestal resorption, and defect morphology. Following 6 months of healing, all soft tissue measurements were repeated. Forty-nine sites (EMD + DFDBA = 26 sites, EMD alone = 23 sites) were surgically reentered. Statistical analyses were performed using unpaired and paired Student t tests. RESULTS: Analyses showed a significant improvement in soft tissue parameters for both treatment groups (P < 0.001) as compared to preoperative measurements. There were no statistical differences between treatment groups. The probing depth reduction (PDR) for the EMD + DFDBA was 3.6 +/- 0.2 mm, while the EMD alone had a PDR of 4.0 +/- 0.3 mm. The CAL gain for the EMD + DFDBA group was 3.0 +/- 0.3 mm and 3.2 +/- 0.3 mm for the EMD alone group. The mean value for bone fill in the EMD + DFDBA group was 3.7 +/- 0.2 mm (74.9%), while the EMD alone group demonstrated a mean bone fill of 2.6 +/- 0.4 mm (55.3%). While there were no significant differences between the two treatments with regards to soft tissue measurements, the combination of EMD + DFDBA therapy yielded statistically significant improvements in bone fill, crestal resorption, and percentage of sites gaining greater than 50% and 90% bone fill when compared to EMD alone (P < 0.001). CONCLUSION: The results of this study indicate that there may be an enhancement of hard tissue parameters when enamel matrix derivative is added to demineralized freeze-dried bone allograft.     

Predictability of clinical outcomes following regenerative therapy in intrabony defects

BACKGROUND: Demineralized bone matrix (DBM) and guided tissue regeneration (GTR) support substantial gains in clinical attachment level (CAL), reductions in probing depth (PD), and gains in defect fill compared to open flap debridement (OFD) in intrabony defects. Although these regenerative therapies support improvements in mean clinical parameters, it is unclear whether the procedures improve the predictability of clinical outcome. The purpose of this study was to examine the relative variability in clinical outcome measures, independent of the magnitude of gains, in regenerative studies comparing DBM or GTR to OFD therapy for the management of intrabony defects. For comparative purposes, a similar analysis was performed evaluating the consistency of clinical outcomes with other (non-DBM) bone replacement graft (BRG) materials relative to OFD alone. METHODS: Fifty-five randomized controlled clinical trials comparing regenerative therapy (seven DBM, 22 BRG, and 26 GTR) to OFD and meeting inclusion criteria provided mean change scores (pretreatment to post-treatment) and variance estimates for CAL, PD, and bone fill, allowing for calculation of a coefficient of variability (CV) for each measure within studies. The mean CV for each measure was submitted to an analysis of variance or covariance with repeated measures (P < or =0.05) to compare relative variation in treatment outcomes. RESULTS: DBM was associated with a significantly lower relative variability (mean +/- SE) in CAL gain (96.3 +/- 38.6 versus 137.7 +/- 30.9) and defect fill (69.1 +/- 11.2 versus 133.1 +/- 15.3) compared to OFD alone. As a group, other BRGs were found to support significant reductions in variation in CAL and defect fill. GTR therapy was associated with significantly lower CV for CAL compared to OFD (50.6 +/- 5.0 versus 68.7 +/- 8.2, respectively). Variability in defect fill was similar for GTR and OFD. CONCLUSIONS: DBM and GTR therapy support more consistent improvements in clinical parameters; however, with the exception of defect fill following bone grafting, the reduction in variability in clinical outcomes was relatively modest compared to OFD alone. Overall, the treatment of intrabony defects is associated with a relatively high degree of variability in clinical outcome, regardless of therapeutic approach.     

Treatment of intrabony defects with an enamel matrix protein derivative or bioabsorbable membrane: an 8-year follow-up split-mouth study

BACKGROUND: Treatments with either an enamel matrix protein derivative (EMD) or guided tissue regeneration (GTR) have been shown to promote periodontal regeneration. However, until recently, only limited data have been available on the long-term clinical results following these regenerative techniques. Therefore, the aim of this study was to present the 8-year results of a prospective, controlled, split-mouth clinical study evaluating the treatment of intrabony defects with EMD or GTR. METHODS: Ten patients, each of whom displayed one pair of intrabony defects located contralaterally in the same jaw, were randomly treated with EMD or with GTR by means of bioabsorbable membranes. The following clinical parameters were evaluated at baseline and at 1 and 8 years after treatment: plaque index (PI), gingival index (GI), bleeding on probing (BOP), probing depth (PD), gingival recession (GR), and clinical attachment level (CAL). The primary outcome variable was CAL. No statistically significant differences between the groups were found at baseline. RESULTS: The sites treated with EMD demonstrated a mean CAL change from 9.5 +/- 1.2 mm to 6.3 +/- 1.3 mm (P <0.001) and 6.7 +/- 1.6 mm (P <0.001) at 1 and 8 years, respectively. No statistically significant differences were found between the 1- and 8-year results. Sites treated with GTR showed a mean CAL change from 9.7 +/- 1.3 mm to 6.7 +/- 0.9 mm (P <0.001) at 1 year and 6.8 +/- 1.2 mm (P <0.001) at 8 years. The CAL change between 1 and 8 years did not present statistically significant differences. Between the treatment groups, no statistically significant differences in any of the investigated parameters were observed at 1 and at 8 years. However, the study does not have the statistical power to rule out the possibility of a difference between the two groups. CONCLUSIONS: Within their limits, the present results indicate the following: 1) the clinical improvements obtained following treatment with EMD or GTR can be maintained over a period of 8 years; and 2) further studies of much higher power need to be performed to support equivalence.     

Enamel matrix proteins in the treatment of deep intrabony defects

BACKGROUND: The present study evaluated the healing of enamel matrix derivative (EMD) proteins in the treatment of periodontal lesions with deep intrabony defects. METHODS: Ten deep intrabony defects in 7 periodontal patients were treated and followed for 1 year. The sites had a probing depth (PD) > or = 8 mm; clinical attachment level (CAL) > or = 9 mm, and intrabony component depth > or = 5 mm. All subjects received therapy prior to surgery and had a plaque score (PI) < or = 10%. Full thickness flaps were elevated buccally and lingually, granulation tissue was removed from the defects, and the root surfaces were planed. A 24% EDTA gel was applied followed by the enamel matrix protein preparation. The flaps were closed with interrupted sutures. The patients rinsed with a chlorhexidine solution twice a day for 6 weeks. They were recalled every 2 weeks for 6 months for professional tooth cleaning and then every 4 weeks for an additional 6 months. The experimental sites were re-examined 6 and 12 months after regenerative surgery. RESULTS: At the 1-year examination, the mean CAL gain was 6.5 mm, the mean PD was 3.2 mm, and mean radiographic bone fill was 4.7 mm. CONCLUSIONS: The application of enamel matrix proteins in combination with open flap curettage and root planing resulted in a gain of CAL and bone fill in deep intrabony defects.