LONG TERM EVALUATION OF BIOMATERIAL APPLICATION IN SURGICAL TREATMENT OF PERIODONTITIS

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1 JOURNAL OF PHYSIOLOGY AND PHARMACOLOGY 2008, 59, Suppl 5, M. ZIETEK 1, T. GEDRANGE 2, M. MIKULEWICZ 3 LONG TERM EVALUATION OF BIOMATERIAL APPLICATION IN SURGICAL TREATMENT OF PERIODONTITIS 1 Department of Periodontology, Wroclaw Medical University, Poland; 2 Department of Orthodontics, Preventive and Pediatric Dentistry, Ernst-Moritz-Arndt University Greifswald, Germany; 3 Department of Dentofacial Orthopedics and Orthodontics, Individual Laboratory of Facial Growth Defects, Wroclaw Medical University, Poland Regenerative treatment of periodontally damaged teeth is a demanding task. Advantages which comes with use of biomaterials are mainly connected with fact that traditional, surgical treatment protocols often do not lead to bone regeneration. The aim of this research was to evaluate clinical and radiological effectiveness of surgical periodontal treatment (with application of HA-Biocer, Biogramu, Bio-Oss) after eight years prior to surgical protocol. Clinical evaluation consisted of measuring pocket depths with perio probe, than evaluation of API (approximal plaque-index) hygiene index (%). Calculation of modified sulcus bleeding index SBI (%) by Muhlemann and Son was done. Engelberger, Marthaler and Rateitschak index on x- rays was calculated. Routine check up eight years after surgical treatment of periodontitis with use of biomaterials was conducted on 32 patients (20 woman, 12 men). The group of patients was divided into: 28 patients with chronic periodontitis (CP), and 4 patients with general aggressive periodontitis (GAP). Eight years after surgical treatment increase of bleeding areas were observed in all applied biomaterials. For Bio-Oss average percent of SBI 45.2% (±24.3), for Biogran 62% (± 36.2) and respectively for HA-Biocer 51% (±33.2) API index (%) on teeth proximal surfaces was estimated for Biogran 47%, BioOss 46.5% and for HA- Biocer 45.6%. Mean pocket depth (mm) has decreased in case of all applied biomaterials. Radiological index was also calculated. Decrease of index value was stated. Outcomes of 8 years study indicate, decrease of oral hygiene, increase bleeding, decrease of Engelberger, Marthaler, Rateitchak index. It is necessary to perform routine check up of and control on oral hygiene. It seems to be important to mobilize patients to preserve high oral hygiene. Key words: periodontitis, biomaterials, bone graft material

2 82 INTRODUCTION Regenerative treatment of damaged teeth during periodontitis is a demanding task. In addition to the appropriate flap technique and application of the regenerative materials, it requires control of the bacterial infection that caused the periodontitis. A pre- and post -operative hygiene phase and patient motivation are therefore basic requirements for therapeutic success. The typical aims of regenerative treatment are; restoration of the complete tooth attachment apparatus with bone, cement, and ligament, long-term tooth retention, positive aesthetic appearance (1). Advantages which comes with use of biomaterials are mainly connected with fact that traditional, surgical treatment protocols often do not lead to bone healing. Contemporary biomaterials (for regenerative bone treatment) can be divided into autogenic bone grafts (a graft between individuals of the same species, the same genotypes) and allogenic bone grafts (a graft between individuals of the same species, but of different genotypes) and biomaterials as bone substitutes xenogenic and alloplastic (synthetic). Differentiation of bone substitutes biomaterials can be more specific: xenogenic (from vertebrates) -(Bio-Gen, Bio- Oss, Osteograf/N), (from invertebrates)- (ALgipore, Biocoral, ProOsteon), alloplastic - hydroxyapatite (HA Biocer, Interpole 200, OsteGen, OsteGraf), polimery (HTR Synthetic Bone, Ionos), tricalcium phosphates (Cerasorb), biologically active glasses (Biogran, PerioGran, PerioGlass) (2). Considered as gold standard autogenic transplantation is applied in cases with massive bone loss or in areas in which conditions for bone regeneration are not favorable. Because of continued increasing of characteristics of synthetic materials and what goes behind possibilities of bone regeneration biomaterials are wider applicated (3). It s estimated that all over the world about 1 million of grafts are preformed a year (4). The aim of this research was to evaluate clinical and radiological effectiveness of surgical periodontal treatment (with application of HA-Biocer, Biogramu, Bio- Oss) after eight years after to surgical intervention. Assessment covered oral hygiene, inflammation of perio tissues, depth of pockets and regeneration of alveolar bone. MATERIAL AND METHODS To perform long term evaluation of biomaterial application in surgical treatment of periodontitis group of formerly treated patients were ask to visit Department of Periodontology of Wroclaw Medical Academy for routine check up. Diagnostics of periodontitis was conducted under regulation of international criteria (5). The local Ethic Committe approved this project and informed consent was obtained from each patient. For surgical treatment those patients were qualified who presented pockets with depth at least 6 mm. All patients were instructed how to keep oral hygiene on excellent level, all old and leaking fillings were restored, also scaling was performed (with root

3 83 planning). In cases with endo-perio syndrome endodontic treatment was performed. Mouth washes were advised. Afterwards surgical protocol was applied. Surgical protocol consisted of: total mobilization of mucoperiosteal flap, cleaning of pathological pockets and root planning and then bone pockets were filled up with hydroxyapatite HA-Biocer, active bio glass Biogran or Bio-Oss. After wound was sewed surgical dressing was applied for 7-10 days. Patients with diagnosed LAP or GAP where given antibiotics for 7-10 days. Clinical and radiological evaluation was performed on first visit, then consecutive 1 year, two years and four, and eventually eight years after surgery. Patients did get their routine check ups (every 6 months) in regional medical centers. Clinical evaluation consisted of measuring pocket depths with perio probe (calibrated within 1 mm) on four dental surfaces, than evaluation of API (approximal plaque-index) hygiene index (%) on proximal surfaces. Calculation of modified sulcus bleeding index SBI (%) was performed. In the end Engelberger, Marthaler and Rateitschak index on x-rays was calculated. In statistical analysis t- Student test was applied (level of significance 0.05). RESULTS Routine check up eight years after surgical treatment of periodontitis with use of biomaterials was conducted on 32 patients (20 woman, 12 men) with age between (average age for woman 49.3, for men 50.2). The group of patients was divided into: 28 patients with chronic periodontitis (CP), 4 patients with general aggressive periodontitis (GAP). On that group 48 surgical treatment protocols were performed (18 with use of Biogran, 16 Ha-Biocer, 14 Bio-Oss). Eight years after surgical treatment increase of bleeding areas was observed in all applied biomaterials. For Bio-Oss average percent of SBI (sulcus bleeding index) was 45.2% (±24.3), for Biogran 62% (± 36.2) and respectively for HA-Biocer 51% (±33.2) (Table 2). In evaluated group of patients unsatisfied oral hygiene level was stated. API index (%) on teeth proximal surfaces was estimated for Biogran 47%, Table 1. Mean API value eight years after periodontal surgery using various biomaterials. Biogran Bio-Oss HA-Biocer (%) 47 46,5 45,6 Table. 2. Mean SBI value before and after periodontal surgery. Control period Bio-Oss Biogran HA-Biocer (%) Before treatment year years years 43, ,8 8 years 45,

4 84 BioOss 46.5% and for HA-Biocer 45.6% (Table 1.). In eight years control period (after surgical treatment of periodontitis) - mean pocket depth (mm) has decreased in case of all applied biomaterials. Data s presenting change of mean pocket depth are presented in Table 3. Radiological index (Engelberger, Marthaler and Rateitschak) was calculated and outcomes were analyzed and compared with values calculated in recent years. Decrease of index value was stated. Eight years after surgical intervention average value of radiological index in Biogran group was higher than in Bio-Osse and HA-Biocer groups p<0.05 (Table 4). DISCUSSION Efficiency of performed surgical treatment with use of biomaterials can be evaluated in three ways: clinical, histopathological and radiological examination. Clinical examination the most important one does not give answer to question what kind of changes has gone inside the bone structure. In our study we have resigned of histological examination (because of it s invasiveness) and have focused on clinical and radiological examination. In group of 14 patients Bio-Oss (spongy structure) xenogenic, bone substitute biomaterial was applied. In literature is consisted that early products of that Table. 3. Mean pocket depth (mm) before and after periodontal surgery. Control period Bio-Oss Biogran HA-Biocer (mm) Before treatment 6,69 7,36 6,9 1 year 3,25 3,9 3,75 2 years 3,16 3,85 4,22 3 years 3,05 3,81 4,2 4 years 3,02 3,97 3,68 8 years 3,00 3,90 3,63 Table. 4. Mean values of the radiographic Engelberger, Marthaler i Rateitschak index improvement after periodontal surgery. Control period Bio-Oss Biogran HA-Biocer (mm) 1 year 11,4 13,5 13,9 2 years 12,1 12,5 12,3 3 years 12,0 12,4 12,5 4 years 4,98 10, years 4,91 9,65 5,20

5 biomaterial type, didn t permit to reach satisfying results because of histological reasons (6). Others reported about rests of detergents and proteins (7). Contemporary findings confirm material s ability for osteointegration and successful regeneration of bone (8, 9). In next group alloplastic, hydroxyapatite HA-Biocer was applied. Hydroxyapatites introduced for clinical trials in late 70 s of last century falls into slow resorption from bone structure. This material can be produced as independent powder or as a mixture with bone (10). The last applied material was biologically active glass. The main ingredients of such biomaterial are: SiO 2, Na 2 O, CaO and P 2 O 5. Depending on mass of natrium oxide active glass can be differentiated from soluble to insoluble form (11). Biologically active glasses present higher mechanical strength comparing to hydroxyapatite skeleton (9). Other reported that application of biologically active glasses (in form of grains) leads to faster regeneration of bone tissue (10). In our study in all three patients groups we found up decrease of mean pocket depth (mm) after periodontal surgery with application Bio-Oss, HA-Biocer and Biogran. Findings in other study reported lack of important statistically differences in decrease of mean pocket depth, in most applicated biomaterials 50% reduction of pocket depth was reached. In summary authors confirmed that degree of improvement of clinical indexes varies and is connected with type of applied surgical protocol (12-14). There is lack of findings in the literature that deals with long term evaluation after regenerative treatment. Perrson at al. reported (9 years control period), that apposition/loss of bone tissue appears within two years form performed surgical attempt. Afterwards stabilization of reached outcomes arrives. Support of reached treatment results was possible due to preservation of high oral hygiene (12, 15, 16). In must be emphasized that basing on reached outcomes in can be stated that use of biomaterials on evaluated 8 years period is an effective method of regenerative treatment of damaged bone areas during periodontitis. Outcomes of 8 years study indicate, decrease of oral hygiene, increase bleeding, decrease of Engelberger, Marthaler, Rateitchak index. It must be underline that applied biomaterials caused bone tissue regeneration which did not degenerate after eight years, It is necessary to perform routine check up of and control on oral hygiene. It seem to be important to mobilize patients to preserve high oral hygiene. Conflicts of interest statement: None declared. 85 REFERENCES 1. Proff P, Bayerlein T, Fanghanel J, Allegrini S Jr, Gedrange T. Morphological and clinical considerations of first and second permanent molar eruption disorders. Ann Anat 2006; 188: Nasr HF, Aichelmann-Reidy ME, Youkna RA. Bone and bone substitutes. Periodontology 2000; 19:

6 86 3. Henkel KO. Comparison of a new calcium phosphate formula versus conventional calcium phosphate matrices in treating bone defects. Key Engineering Materials 2005; Greenwald AS, Boden SD, Goldberg VM, Khan Y, Laurencin CT, Rosier RN. Bone-graft substitute: facto, fictions, and applications. J Bone Joint Surg 2001; 83: Armitage C. Development of a classification system for periodontal diseases and conditions. Ann Period 1999; 4: Melher AH. The use of heterogeneous anorganic bone as an implant material in oral procedures. Oral Surg Oral Med Oral Patol Oral Radiol Endod 1962; 15: Mai R, Hagedorn MG, Gelinsky M et al. Ectopic bone formation in nude rats using human osteoblasts seeded poly(3)hydroxybutyrate embroidery and hydroxyapatite-collagen tapes constructs. J Craniomaxillofac Surg 2006; 34: Callan DP, Rohrer MD. Use of bovine derived hydroxyapatite in the treatment of endentulous ridge defects: A human clinical and histologic case report. J Periodontol 1993; 64: Mai R, Lauer G, Pilling E et al. Bone welding a histological evaluation in the jaw. Ann Anat 2007; 189: Oonishi H, Kushitani S, Yasukawa E. Particular bioglass compared with hygroxyapatite as a bone graft substitute. Clin Orthod 1997; 334: Hench LL, Wilson J. Surface active biomaterials. Science 1984; 226: Persson GR, Falk H, Laurell L. A retrospective radiographic outcome assessment study of intrabony defects treated by osseous surgery or by bone graft procedures. J Clin Periodontol 2000; 27: Richardson CR, Mellonig JT, Brunsvold MA, Mcdonnell HT, Cochran DL. Clinical evaluation of bio-oss: a bovine-derived xenograft for the treatment of periodontal osseous defects in humans. J Clin Periodontol 1999; 26: Ohazama A, Kitamura H, Suzuki M, Yamada S, Hasegawa K. The clinical evaluation of periodontal surgery with porous bone graft material (bio-oss) and collagen membrane (biogide). J Japan Soc Periodont 1999; 41: Czesnikiewicz-Guzik M, Konturek SJ, Loster B, Wisniewska G, Majewski S. Melatonin and its role in oxidative stress related diseases of oral cavity. J Physiol Pharmacol 2007; 58: Gonciarz M, Wloch M, Gonciarz Z. Helicobacter pylori in liver diseases. J Physiol Pharmacol 2006; 57: R e c e i v e d : July 24, 2008 A c c e p t e d: October 15, 2008 Author s address: Prof Dr. Marek Zietek, Department of Periodontology, Wroclaw Medical University, Krakowska 26, Wroclaw, Poland; paradont@stom.am.wroc.pl