Puneet Mehta et al. /JPR:BioMedRx: An International Journal 2013,1(7), Available online through

Transcription

1 Research Article ISSN: 988 Puneet Mehta et al. /JPR:BioMedRx: An International Journal,(7),777 Available online through The therapeutic and regenerative effects of Periosteum in the treatment of gingival :A Systematic Review Puneet Mehta, Sheeja Varghese, Sankari.M, N.D.Jayakumar Saveetha Dental College,, PH Road, Chennai77, India Received on:; Revised on:7; Accepted on: ABSTRACT Aim:The aim of this systematic review is to review the literature on regenerative effects of periosteum in the management of gingival. Materials and methods:an Electronic search through PUBMED upto and manual search was performed and a hand search of peer reviewed journals of periodontology for relevant articles were performed. Studies included were randomized control trials, case series, case reports & animal studies with data on the regenerative effects of periosteum in treatment of gingival and its comparison with other techniques were included.results :A total of studies were included.the studies on gingival showed improvement in all parameters when compared to baseline values, randomized control showed that periosteum is equally effective as Sub epithelial Connective Tissue Graft. Keywords: Periosteum, Gingival,. INTRODUCTION The major goal of periodontal therapy is to reconstruct the periodontal defects caused by periodontal disease which include osseous defects, furcation defects and gingival. Various bone and soft tissue grafts as well as synthetic materials either alone or in combination have been tried in the past for managing various periodontal defects and showed varying degrees of predictability. Each material has its own advantages and limitations and the choice among them depends on factors related to defect, patient comfort, aesthetic demand and the cost. Many studies have reported the usefulness of periosteum in periodontal regeneration. The adult human periosteum is highly vascular and is known to contain fibroblasts, osteoblasts and their progenitor cells, and stem cells []. The periosteum comprises of two layers, an inner cellular or cambium layer, and an outer fibrous layer. The inner layer contains numerous osteoblasts and osteoprogenitor cells and the outer layer is composed of dense collagen fiber, fibroblasts, and their progenitor cells [ ]. Recently periosteum has been used for the management of gingival defects and has shown promising results over the gold standard technique. The present systematic review is undertaken to evaluate regenerative effect of periosteum in the treatment of gingival. *Corresponding author. Puneet Mehta Saveetha Dental College,, PH Road, Chennai77, India MATERIALS AND METHODS FOCUSSED QUESTION Is periosteum effective in the management of gingival? PICO ALYSIS Patients Gingival. Intervention or free graft, tissue engineered cultured periosteum, autogenous periosteal barrier membrane. Comparison Any other technique for root coverage such as connective tissue graft, Coronally advanced flap or a within the group comparison with the preoperative and post operative values. OUTCOME VARIAES FOR GINGIVAL RECESSION Primary outcome variable : Complete root coverage (CRC) expressed as percentage. Secondary outcome variables : Recession depth, clinical attachment level, width of keratinized gingiva, wound healing, post operative complications, patients satisfaction & root sensitivity. SEARCH STRATEGY: A search of the electronic database of PUBMED, up to and including was made. Studies included were randomized control trials, case series, case reports & animal studies. JPR:BioMedRx: An International Journal Vol. Issue 7.June 777

2 Puneet Mehta et al. /JPR:BioMedRx: An International Journal,(7),777 The search methodology was applied with the following keywords in PUBMED database: Search Search: (multiple gingival ) ) OR (gingival )) OR (multiple shallow gingival ) ) OR (mul tiple shallow gingival s)) OR (shallow gingival s))and(( ((( (( ((((( ( periosteal graft ) ) OR ( periosteoplasty )) OR ( periosteum ) ) OR (cul tured periosteum)) OR ( marginal periosteal pedicle graf t )) OR (periosteal derived cells)) OR (periosteum therapeautic use)) OR (periosteum therapeutic use)) OR ( periosteum transplantation )) OR (alveolar periosteal cells))) Filters: From // to //, English SELECTION OF STUDIES INCLUSION CRITERIA. Studies which compared the effectiveness of periosteal grafts (free or pedicle, tissue engineered periosteal membrane or cultured periosteal cells) in the management of gingival. Randomized controlled trials, clinical trials, case reports or case series.. studies as well as animal studies. EXCLUSION CRITERIA. Studies not in english language.. Studies with a follow up of less than months (except for animal studies.. Studies where outcome parameters are not clearly mentioned. Studies on gingival included case series [ ] [ ] [7] [ ] and RCT [], and all had a follow up period of year. SEARCH FLOWCHART Potentially Relevant Publications Identified From Electronic Search. n =8 Potentially Relevant Full Text Articles Retrieved For Detailed n = Potentially Relevant Publications Included. n = Publications Included in the Present Systematic Review. n = Publications Excluded Based On Abstract n = Potentially Relevant Publications Included Based On Manual Search. n = Publications Excluded On The Basis Of Full Text n = Table :Excluded Articles Excluded articles on the basis of full text Cortellini et al [] Table Variables of Interest S.No Gingival Recession depth reduction CAL Complete Root coverage Width of keratinized gingiva Patients satisfaction Wound healing..... Reasons for exclusion Free gingival graft used rather than a periosteal Figure : Graph depicting risk of bias major criteria GINGIVAL RECESSION GINGIVAL RECESSION LOW LOW MODERATE HIGH Figure : Graph depicting risk of bias minor criteria JPR:BioMedRx: An International Journal Vol. Issue 7.June 777

3 Puneet Mehta et al. /JPR:BioMedRx: An International Journal,(7),777 Table : General information of the articles Sr no Author and year of publication Mahajhan et al []. Mahajhan et al [] et al 9 [] Virnik et al. [7] 9 Gaggal et al [] Sr. Reference No Type of study Study design Randomised controlled clinical trial Sample size N= ( men and women) N=( males & females) N= ( males females) N = N = patients Ethnicity Austrian Austrian Age years. to yrs old years of 7 years 7 years Defect Millers class I &class II Multiple Millers class I and Class II gingival Millers class I & class II Millers class I, Class II & ClassIII. Millers class I,Class II & ClassIII. Control Subepithelial connective tissue graft General information of selected articles table :results: gingival et al [] et al [] et al [] 9 Virnik et al. [7} 9 Gaggal et al [] Study Groups SCTG periosteal Clinical parameters. RD PPG. ±.8 Months. ±.7 SCTG. ±.9 Months. ±.8.7±. Months. ±.7.7±.9 Months. p value (RD) <. <. <. Change in CAL. 8±. Months ±..±. months.±.. 8±. Months ±..±. months.±. P value (CAL) Complete Root Coverage 9. % 88.% 9.9% 9.8% 9.8% Change in WKT.±. Months.8±.. ±.7 Months.±. At baseline.7±.78 months.7±.7. ±. Months.±..±. months.±.. ±. Months.±..±. months.±. P value (WKT).7. <. Test peicle graft pedicle grft Patient satisfaction Patient discomfort was significantly lesser in PPG group during the treatment and after the treatment when compared to thesctg group(p<.). Duration Methodology of year Clinical year Clinical I year Clinical year Clinical year Clinical Wound healing Patients of the test group were graded as score i.e fully satisfied Interpretation of Results Within the group both groups showed significant improvement from the baseline in all the parameters except for WKT. Between the group no significant difference except for patient discomfort which was significantly less for PPG group. At the end of year,there was significant improvement from the baseline in the clinical parameters. After one year, a complete reduction in depth was noticed in all the cases. The treatment resulted in all the clinical parameters from baseline. The treatment resulted in all the clinical parameters from baseline. JPR:BioMedRx: An International Journal Vol. Issue 7.June 777

4 Puneet Mehta et al. /JPR:BioMedRx: An International Journal,(7),777 Table : Level of evidence Sr no Author &year Study design Level of evidence Mahajhan et al [] RCT Mahajhan et al [] CASE SERIES et al [] 9 CASE SERIES Virnik et al [7] 9 CASE SERIES Gaggal et al [] CASE SERIES number of studies total number of studies periosteum is more effective periosteum is less effective periosteum is equally effective number of studies Free graft Pedicle graft Cultured periosteum Tissue engineered periosteum depth clinical attachment level width of keratinised gingiva patient satisfaction wound healing Figure : Graph depicting the effectiveness of periosteum against other techniques for gingival defects gingival Figure :type of periosteum used DISCUSSION This systematic review included studies which assessed the effectiveness of the periosteum with respect to baseline parameters and with other techniques in the management of gingival defects. A total of studies were included in this review which included case series [][][7][] and RCT [], and all studies had a follow up period of year. Number of Studies gingival Figure: duration of study number os studies > year year < year no of studies periosteum effective periosteum not effecive In all the studies [ ][][][7][] periosteum was used as a and all studies showed an improvement in all the parameters when compared to baseline values. One randomized control clinical trial [] showed significant results with reference to patient satisfaction when compared to the SCTG group. The reason for better patient satisfaction could be because of less intra operative discomfort as SCTG needs a second surgical site. The above mentioned RCT showed a low risk of bias as there was satisfactory randomization with proper allocation concealment and assessor blinding, the limitations of the study included non mention of sample size calculation and drop outs were encountered in the study. LIMITATIONS This review included articles only from PUBMED database and hand search of the Periodontology journals and also studies in english language only were included. In this review the results were compiled based only on the published articles and not the raw data of the original study. depth clinical attachment level width of keratinized gingiva patient satisfaction wound healing Figure : Graph depicting the effectiveness of periosteum in the outcome paramteres from baseline for gingival defects. JPR:BioMedRx: An International Journal Vol. Issue 7.June On the assessment of the risk of bias the RCT [] on gingival showed a low risk of bias as there was satisfactory randomization with proper allocation concealment and assessor blinding.the limitations of the study included non mention of sample size calcula 777

5 Puneet Mehta et al. /JPR:BioMedRx: An International Journal,(7),777 tion and drop outs were encountered in the study. FUTURE SCOPE Quality interventional studies with a larger sample size and a longer follow up period are needed to compare the efficacy of periosteum with gold standard technique and other techniques in the management of gingival to make it one of the most leading procedures in its management. CONCLUSION Based on the results obtained from the present systematic review it can be concluded that periosteum is effective in improving the clinical parameters from the baseline and has also showed better patient satisfaction when compared with SCTG. Evidences are limited to prove that periosteum is more effective or equally effective as gold standard procedures for the management of gingival. Larger interventional trials with an adequate sample size are required to make it one of the most preferable procedures for the management of gingival. REFERENCES:. A, A Bharadwaj, P : Comparison of periosteal and subepithelial connective tissue graft for the treatment of gingival s defects. Australian Dental Journal ; 7: 7.. A for the treatment of gingival defects: A Novel technique.australian Dental Journal 9; :.. Ajay :Periosteum: A Highly Underrated Tool in Dentistry International Journal of Dentistry, Volume, Article ID 778, pages.. Ajay Treatment of Multiple Gingival Recession Defects Using : A Case Series J Periodontol ;8:.. Alexander Gaggal,Daniel jamming,albino Triaca,Fredrich Michael Chiari: A new technique of periosteoplasty for covering s: preliminary report and first clinical results.perio :vol, issue :.. C. A. Squier, S. Ghoneim, and C. R. Kremenak: Ultrastructure of the periosteum from membrane bone, Journal of Anatomy, vol. 7, pp. 9, Sascha Virnik,Friedrich Michael Chiari,Alexander Gaggl. Periosteoplasty for covering gingival s: Clinical results Clinical, Cosmetic and Investigational Dentistry 9:. 8. Euloir Passanezi, D.D.S, Mario Eduardo Al. F. Alves, D.D.S, Waldyr A. Janson, D.D.S.,Morris P. Ruben, D.D.S: Activation and Root Demineralization Associated With the Horizontal Sliding Flap J.Periodontol. August, 979, Volume, No 8, H. Smukler, D.M.D, H. M. Goldman, D.M.D. Laterally Repositioned Stimulated Osteoperiosteal s in the Treatment of Denuded Roots A Preliminary Report.J.Periodontol. August, 979, Volume, No 8, Cortellini P Tonetti M Prato GP : The partly epithelialized free gingival graft (pefgg) at lower incisors. A pilot study with implications for alignment of the mucogingival junction J Clin Periodontol. Jul;9(7):78. Source of support: Nil, Conflict of interest: None Declared JPR:BioMedRx: An International Journal Vol. Issue 7.June 777