Effect of Guided Tissue Regeneration on Newly Formed Bone and Cementum in Periapical Tissue Healing after Endodontic Surgery: An In Vivo Study in the Cat

doi:10.1016/j.joen.2011.10.002

Journal of Endodontics

Volume 38, Issue 2, February 2012, Pages 163-169

https://doi.org/10.1016/j.joen.2011.10.002 Get rights and content

Abstract

Introduction

The purpose of this study was to evaluate the influence of anorganic bovine bone as a grafted biomaterial on newly formed bone and cementum in periapical regions after surgical endodontic treatment in cats.

Methods

After inducing apical periodontitis in 9 cats, root canal and surgical endodontic treatment were performed on 72 roots of first and second maxillary premolars. Bone defects were treated with biomaterial particles + a membrane, biomaterial only, a membrane only, or left unfilled (control). Histomorphometry on nondecalcified sections were performed at 3 and 6 months after surgery. Analysis of variance with repeated measures was used within 2 and 3 subject factors to analyze newly formed bone, cementum, biomaterial conduction, and resorption.

Results

At each time period, bone formation was greater at the grafted membrane-protected sites than in the grafted-unprotected sites. At 6 months, the bone area fraction at membrane nongrafted sites was greater than in the grafted-protected sites. The new cementum was significantly greater at 6 months than at 3 months and greater at the grafted membrane-protected sites over the unprotected ones at 6 months. Statistically, the grafted biomaterial, the membrane, and the time contributed significantly to the amount of new bone (P < .05) with no significant interaction. Biomaterial osteoconduction was significantly affected by the time. All 3 variables showed a significant interaction on new cementum.

Conclusions

There was significantly more bone formation after surgical endodontic treatment when membrane and bone grafts were used as compared with bone grafts only or unfilled control sites. However, it appears that the key factor to the enhanced tissue regeneration is the membrane and not the grafted biomaterial.

Section snippets

Materials and Methods

The Institutional Animal Care and Use Committee at Tel Aviv University approved the study, which was performed on 9 young female adult cats born and raised at the Tel Aviv University animal facility. Cats weighed an average of 3.5 kg (range, 2.2–4.8 kg) and were matched for age (16–18 months) and sex (female). Animals were individually housed and maintained on a commercial animal diet (Nestle, Vevey, Switzerland) and water ad libitum. After each surgical procedure, a soft diet was administered

Bone Area Fraction

At 3 months, the mean bone area fraction was 14.0% ± 10.8% (mean ± standard deviation) at the uncovered grafted sites, 25.5% ± 4.8% at the grafted membrane-protected sites, 31.4% ± 12.3% at the nongrafted membrane-covered sites, and 25.0% ± 16.2% at the control sites (Fig. 6A). At 6 months, mean bone area fraction was 30.2% ± 5.7% at the grafted membrane-protected sites, 21.6% ± 10.7% at the unprotected sites, 38.7% ± 7.4% at the nongrafted membrane-covered sites, and 30.0% ± 17.3% at the

Discussion

In periodontal therapy, there is a consensus on the efficacy of GTR principles in periodontally involved intrabony defects including fenestrated type defects 33, 34. The major difference between endodontic and periodontal therapy is that in endodontic treatment situations the periodontium is usually healthy and tissue removal is only for access, whereas periodontal treatment is initiated in diseased tissues. Furthermore, the periodontal defect is mostly an open wound, whereas the endodontic

Acknowledgments

The authors are indebted to Biomet3I for providing the bioresorbable membranes, to Dr Naam Kariv for the animal care, to Mrs Ilana Gelerntner for the statistical analysis, and to Ms Rita Lazar for editorial assistance.

The authors deny any conflicts of interest related to this study.

References (52)

I. Tsesis et al.
Outcome of surgical endodontic treatment performed by a modern technique: a meta-analysis of literature
J Endod
(2009)
I. Tsesis et al.
Retrospective evaluation of surgical endodontic treatment: traditional versus modern technique
J Endod
(2006)
S. Kim et al.
Modern endodontic surgery concepts and practice: a review
J Endod
(2006)
J.W. Harrison et al.
Wound healing in the tissues of the periodontium following periradicular surgery. III. The osseous excisal wound
J Endod
(1992)
H. Maguire et al.
Effects of resorbable membrane placement and human osteogenic protein-1 on hard tissue healing after periradicular surgery in cats
J Endod
(1998)
S.H. Baek et al.
Bone repair of experimentally induced through and through defects by Gore-Tex, Guidor, and Vicryl in ferrets: a pilot study
Oral Surg Oral Med Oral Pathol Oral Radiol Endod
(2001)
P.F. Bernabé et al.
Histologic evaluation of the use of membrane, bone graft, and MTA in apical surgery
Oral Surg Oral Med Oral Pathol Oral Radiol Endod
(2010)
S. Taschieri et al.
Efficacy of xenogeneic bone grafting with guided tissue regeneration in the management of bone defects after surgical endodontics
J Oral Maxillofac Surg
(2007)
T. Dietrich et al.
Periapical and periodontal healing after osseous grafting and guided tissue regeneration treatment of apicomarginal defects in periradicular surgery: results after 12 months
Oral Surg Oral Med Oral Pathol Oral Radiol Endod
(2003)
K. Garrett et al.
The effect of a bioresorbable matrix barrier in endodontic surgery on the rate of periapical healing: an in vivo study
J Endod
(2002)

G. Pecora et al.

Barrier membrane techniques in endodontic microsurgery

Dent Clin North Am

(1997)

L.F. Stassen et al.

Use of anorganic bone in periapical defects following apical surgery—a prospective trial

Br J Oral Maxillofac Surg

(1994)

D. Tadic et al.

A thorough physicochemical characterisation of 14 calcium phosphate-based bone substitution materials in comparison to natural bone

Biomaterials

(2004)

K.D. Werber et al.

Osseous integration of bovine hydroxyapatite ceramic in metaphyseal bone defects of the distal radius

J Hand Surg Am

(2000)

J.D. Bashutski et al.

Periodontal and endodontic regeneration

J Endod

(2009)

J.O. Andreasen et al.

Modes of healing histologically after endodontic surgery in 70 cases

Int J Oral Surg

(1972)

J.C. Douthitt et al.

Histologic assessment of healing after the use of a bioresorbable membrane in the management of buccal bone loss concomitant with periradicular surgery

J Endod

(2001)

E.S. Apaydin et al.

The effect of calcium sulfate on hard tissue healing after periradicular surgery

J Endod

(2004)

R.A. Barkhordar et al.

Histologic evaluation of a human periapical defect after implantation with tricalcium phosphate

Oral Surg Oral Med Oral Pathol

(1986)

R.J. Beck-Coon et al.

An in vivo study of the use of a nonresorbable ceramic hydroxyapatite as an alloplastic graft material in periapical surgery

Oral Surg Oral Med Oral Pathol

(1991)

J.L. Gutmann et al.

Posterior endodontic surgery: anatomical considerations and clinical techniques

Int Endod J

(1985)

J.L. Gutmann et al.

Surgical Endodontics

(1991)

G. Pecora et al.

The use of calcium sulphate in the surgical treatment of a ‘through and through’ periradicular lesion

Int Endod J

(2001)

L. Lin et al.

Guided tissue regeneration in periapical surgery

J Endod

(2010)

S.I. Tobón et al.

Comparison between a conventional technique and two bone regeneration techniques in periradicular surgery

Int Endod J

(2002)

S. Taschieri et al.

Efficacy of guided tissue regeneration in the management of through-and-through lesions following surgical endodontics: a preliminary study

Int J Periodontics Restorative Dent

(2008)

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This study investigates the feasibility of integrating a piezoelectric device (PIEZO) into a dynamic navigation system (DNS) for bone-window guided surgery. It compares the accuracy and efficiency of PIEZO + DNS to PIEZO + Freehand (FH) procedure for bone-window cutting and root-end resection (RER).
Forty-eight mandibular molars of 3D-printed surgical jaw models were divided into two groups: PIEZO + DNS (n = 24) and PIEZO + FH (n = 24). Cone-beam computed tomography scans were taken before and after the procedure. The procedure was virtually planned on X-guide software. The bone-window cutting and RER were conducted with a PIEZO under dynamic navigation in the PIEZO + DNS group and using the dental operating microscope in the PIEZO + FH group. The 2D- and 3D-accuracy deviations and angular deflection were measured for the bone window cut. The root length resected and resection angle were calculated. The bone window cut, RER, total operating time, and number of mishaps were recorded.
PIEZO + DNS was more accurate than PIEZO + FH for bone-window cutting, showing fewer 2D and 3D deviations and less angular deflection (P < .05). The resection angle was lower in the PIEZO + DNS (P < .05). The bone-window cut and total operating time were significantly reduced using a DNS (P < .05). There was no difference in the number of mishaps (P > .05).
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Bone grafting material is not necessary for the defect. One study showed improved healing in cats when a barrier membrane was used (with or without a bone graft), compared with closure with a bone graft alone or with no graft/membrane.99 With large periapical defects, a membrane may be considered.
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The present study compared the in vivo efficacy of a novel synthesized polycaprolactone (PCL)/polyethylene glycol (PEG)/bioactive glass (BG) nanocomposite membrane versus a cytoplast (Cy) membrane in terms of the average percentage of new bone formation and inflammation levels.
In the present interventional animal study, 12 male New Zealand rabbits were tested. In the parietal bone of the rabbits, 24 defects were prepared (2 defects for each rabbit), which were divided into 3 equal groups (Cy, PCL, and control). Each rabbit's calvarial bone was prepared for the histologic and histomorphometric survey. The amount of regenerated bone (ie, length, area, percentage), necrosis rate, fibrosis (fibrosis plus and percentage), and inflammation in the standard defects of parietal bone in the rabbits were examined and compared after 10 weeks.
A significant difference was found between the Cy and PCL groups regarding the mean area and thickness of the bone. We also found a significant difference in the bone length, area, and percentage formed between PCL and control groups. Also, the rate of fibrous tissue formation was significantly different statistically between the PCL and control groups. The results showed the influence of the PCL membrane in generating more bone and less fibrous tissue. In all 3 groups, negligible inflammation and no necrosis was observed.
The results of the present study have shown that combining PCL, PEG, and BGs could be promising for bone regeneration in jaw defects, around dental implants, and in oral and maxillofacial defects.
The Effect of Regeneration Techniques on Periapical Surgery with Different Protocols for Different Lesion Types: A Meta-Analysis
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An overview of the selection process is shown in Figure 1. Full-text versions of a total of 17 studies were obtained for detailed evaluation, and 9 studies were excluded for various reasons6,18-25: 2 did not have a sufficient follow-up time, 1 had a dropout rate greater than 20%, 1 included patients with perforations, 1 failed to report success and failure rates, 3 were not randomized controlled trials, 2 were animal trials, and 1 had no control group (Table 1). Finally, 8 studies (7 in English and 1 in French)3,26-32 were included in this meta-analysis and were subjected to data extraction, risk-of-bias assessment, and data synthesis and analysis.
To evaluate the effect of regeneration techniques (RTs) on the outcome of periapical surgery with different protocols for different lesion types.
PubMed, the Cochrane Library, and Embase were searched from the beginning of time until December 30, 2014. Studies that met the inclusion criteria were systematically evaluated, and a meta-analysis was performed.
Eight randomized controlled trials met the inclusion criteria. A significantly better outcome was found in the combination group (membranes plus bone replacement analogues) (risk ratio [RR], 0.41; 95% confidence interval [CI], 0.22 to 0.77; P = .005) and bone replacement analogue–only group (RR, 0.48; 95% CI, 0.23 to 0.98; P = .04), whereas no significant beneficial effect was found in the membrane-only group (RR, 0.59; 95% CI, 0.29 to 1.17; P = .13). The use of RTs favorably affected the outcome of periapical through-and-through lesions (RR, 0.38; 95% CI, 0.18 to 0.84; P = .02) and large lesions (≥10 mm) (RR, 0.52; 95% CI, 0.28 to 0.97; P = .04), whereas there was no significant benefit of using RTs for 4-wall lesions (RR, 0.54; 95% CI, 0.27 to 1.07; P = .08).
Both the isolated use of bone replacement analogues and the combination of membranes and bone replacement analogues can improve the outcome of periapical surgery, whereas using membranes alone does not have significantly favorable effects. The use of RTs for through-and-through and large lesions should be recommended.
Animal-bone derived hydroxyapatite in biomedical applications
2015, Hydroxyapatite (HAp) for Biomedical Applications
The use of animal bone-derived bone for producing bone grafting and other types of materials with biomedical applications has been a fundamental part of biomaterials science since the 1950s, when Kiel bone was first developed and used. Those early experiences paved the way for the large volume of materials and clinical research that were to follow involving animal bone-derived bone. This chapter deals with the (vertebral) species of animal bone sourced for biomedical materials that was and still is principally bovine bone but that has, in recent times, branched out to include equine, porcine, cervine, ovine, fish, ostrich, and duck-head-sourced bone. The rationales for using animal-derived bone are explored and then the processing, characterization, and dependence of the ultimate phase of hydroxyapatite obtained on the process used to extract it from bone sources are discussed. The scare in Europe and other countries from the emergence of transmissible spongiform encephalopathies in cattle herds approximately 20 years ago and the link to variant Creutzfeldt–Jakob disease (v-CJD) in humans have impelled the need (as dictated by regulatory requirements, notably in Europe) to process animal-origin products, particularly bovine bone using methods that eliminate the possibility of transmission to humans of v-CJD from use of bovine-derived implants. These methods are discussed along with a brief word on the European Commission regulations that make it mandatory for manufacturers of such products to ensure their safety when used in vivo. Finally, the chapter will close with descriptions of some commercially supplied animal bone-derived bone graft materials available on the current market and the surgical studies that have used them. In addition, a selection of other clinical studies involving noncommercially sourced animal bone-derived biomedical materials will be covered. In general, the chapter will serve to show the fundamental reach of these products in the field of biomaterials science and practice.
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: Supported by a grant from Botiss Biomaterials GmbH Germany and by the Alpha Omega Research Fund, Tel Aviv University.

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Basic ResearchEffect of Guided Tissue Regeneration on Newly Formed Bone and Cementum in Periapical Tissue Healing after Endodontic Surgery: An In Vivo Study in the Cat

Abstract

Introduction

Methods

Results

Conclusions

Section snippets

Materials and Methods

Bone Area Fraction

Discussion

Acknowledgments

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Dent Clin North Am

Br J Oral Maxillofac Surg

Biomaterials

J Hand Surg Am

J Endod

Int J Oral Surg

J Endod

J Endod

Oral Surg Oral Med Oral Pathol

Oral Surg Oral Med Oral Pathol

Posterior endodontic surgery: anatomical considerations and clinical techniques

Int Endod J

Surgical Endodontics

The use of calcium sulphate in the surgical treatment of a ‘through and through’ periradicular lesion

Int Endod J

Guided tissue regeneration in periapical surgery

J Endod

Comparison between a conventional technique and two bone regeneration techniques in periradicular surgery

Int Endod J

Efficacy of guided tissue regeneration in the management of through-and-through lesions following surgical endodontics: a preliminary study

Int J Periodontics Restorative Dent

Basic Research
Effect of Guided Tissue Regeneration on Newly Formed Bone and Cementum in Periapical Tissue Healing after Endodontic Surgery: An In Vivo Study in the Cat