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

• Autores: Vincenzo Iorio-Siciliano
• Localización: Journal of periodontology, ISSN 0022-3492, Nº. 10, 2014, págs. 1342-1350
• Idioma: inglés
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• Resumen

  • 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.

    Regenerative periodontal therapy aims at predictably restoring the tooth�s supporting periodontal tissues (i.e., new periodontal ligament [PDL], new root cementum with inserting PDL fibers, and new alveolar bone) lost because of periodontal disease.1 Results from human histologic studies have provided evidence for periodontal regeneration following the use of certain types of bone grafts, barrier membranes (guided tissue regeneration [GTR]), enamel matrix derivative (EMD), or combinations of bone grafts with either GTR or EMD.2-15 Several studies showed that the morphology of the osseous defect plays an important role in the healing capacity of the defect, thus directly influencing the clinical outcomes.16-20 Evidence also indicates that the application of biomaterials without space-making properties such as EMD may not be indicated for the treatment of deep non-contained intrabony defects.18,21 In fact, the results of a controlled clinical study using EMD alone for the treatment of intrabony defects showed that 3-wall defects yielded a 2.7 times higher probability of gaining ?3 mm clinical attachment level (CAL) compared with 1-wall defects.18 In a randomized controlled clinical trial, the application of a non-resorbable titanium-reinforced membrane increased by seven times the probability of obtaining a significant CAL gain of ?4 mm compared with the application of EMD alone in the treatment of non-contained intrabony defects.21 On the other hand, the use of a non-resorbable titanium-reinforced membrane may lead to compromised wound healing once the membrane becomes exposed to the oral environment and contaminated by bacterial biofilms.22,23 Moreover, the application of non-resorbable membranes requires a second surgical intervention for their removal after a healing period of 4 to 6 weeks.22,23 To minimize these inherent shortcomings, the combination of grafting materials and resorbable membranes was proposed for periodontal regeneration in intrabony defects.9-12,24-28 The results of a randomized controlled clinical trial showed that intrabony defects treated with the combination of a deproteinized bovine bone mineral (DBBM) and a collagen membrane (CM) gained an average CAL of 3.3 ± 1.7 mm, whereas control defects treated with open-flap debridement alone yielded a significantly smaller mean CAL gain of 2.5 ± 1.5 mm.25 Mean reductions in probing depth (PD) were also significantly higher in the group treated with the combination approach (3.7 ± 1.8 mm) compared with those in the access flap group (3.2 ± 1.5 mm).25 To avoid membrane exposure and wound infection due to bacterial colonization of the membrane, EMD was used in combination with different bone grafting materials such as autogenous bone (AB), demineralized freeze-dried bone allograft (DFDBA), or DBBM due to its properties in inhibiting epithelial proliferation and enhancing periodontal and bone regeneration.13,14,29-37 Results from comparative studies investigating the application of EMD either alone or in combination with AB, DFDBA, or DBBM indicated less gingival recession (REC) and higher gains of CAL in the combination groups.29-34 Findings from a recent in vitro study evaluating EMD adsorption to the surface of DBBM particles showed that this combination stimulated the release of growth factors and cytokines including bone morphogenetic protein 2 and transforming growth factor-?1.35 Moreover, outcomes from in vitro studies indicated that significantly higher messenger RNA levels of osteoblast differentiation markers such as collagen-1?, alkaline phosphatase, and osteocalcin were detected in osteoblasts and PDL cells cultured on EMD-coated DBBM particles.35,36 These findings suggest that EMD enhances osteoblast and PDL cell attachment, proliferation, and differentiation on DBBM particles and provides a biologic rationale for using this combination in regenerative periodontal therapy.35,36 These in vitro findings appear to support the results from human histologic case reports showing that in intrabony defects the combination of DBBM + EMD may facilitate periodontal regeneration13-15,31 and result in substantial clinical improvements that remain stable up to a period of 5 years.14 Therefore, from both a biologic and a clinical point of view, it is of pertinent clinical interest to evaluate whether in deep, non-contained intrabony defects, the use of EMD may represent an alternative to CM when used in combination with DBBM.

    Hence, the aim of this randomized controlled clinical study is to compare the clinical outcomes in the treatment of non-contained intrabony defects using a combination of EMD and DBBM with that of comparable defects using CM and DBBM after an observation period of 12 months.