Apical approach in periodontal reconstructive surgery with enamel matrix derivate and enamel matrix derivate plus bone substitutes: a randomized, controlled clinical trial

Abstract

Objectives This parallel, randomized controlled clinical trial evaluated the influence of bone substitutes (BS) on the efficacy of the non-incised papillae surgical approach (NIPSA) with enamel matrix derivate (EMD) in resolving deep, isolated, combined non-contained intrabony and supra-alveolar periodontal defects, preserving the soft tissue. Material and methods Twenty-four patients were randomized to treatment with NIPSA and EMD or NIPSA plus EMD and BS. Bleeding on probing (BoP), interproximal clinical attachment level (CAL), interproximal probing depth (PD), recession (REC), location of the tip of the papilla (TP), and width of the keratinized tissue (KT) were evaluated before surgery and at 1 year post-surgery (primary outcomes). Wound closure was assessed at 1 week post‐surgery, and supra‐alveolar attachment gain (SUPRA-AG) was recorded at 1 year post‐surgery. Results At 1 week, 87.5% of cases registered complete wound closure and there were no cases of necrosis, without differences between groups (p > .05). At 1 year, all cases showed negative BoP. A significant PD reduction (NIPSA + EMD 8.25 ± 2.70 mm vs. NIPSA + EMD + BS 6.83 ± 0.81 mm) and CAL gain (NIPSA + EMD 8.33 ± 2.74 mm vs. NIPSA + EMD + BS 7.08 ± 2.68 mm) were observed (p < .001) in both groups, without significant between-group differences (p > .05). The residual PD was < 5 mm in all defects (NIPSA + EMD 2.50 ± 0.67 mm vs. NIPSA + EMD + BS 2.67 ± 0.78 mm). Soft tissues were preserved without significant between-group differences (REC: NIPSA + EMD 0.25 ± 0.45 mm vs. NIPSA + EMD + BS 0.17 ± 0.58 mm, p > .05; KT: 0.00 ± 0.43 mm vs. 0.08 ± 0.67 mm, p > .05). There were improvements in the papilla in both groups (TP: NIPSA + EMD 0.33 ± 0.49 mm vs. NIPSA + EMD + BS 0.45 ± 0.52 mm, p > .05), which was only significant in the NIPSA EMD + BS group (0.45 ± 0.52 mm; p < .05). In both groups, CAL gain was recorded in the supra-alveolar component, showing full resolution of the intrabony component of the defect in all cases (SUPRA-AG: NIPSA + EMD 1.83 ± 1.11 mm vs. NIPSA + EMD + BS 2.00 ± 1.76 mm, p > .05). Conclusions NIPSA and EMD with or without BS seem to be a valid surgical approach in the treatment of isolated, deep non-contained periodontal defects. In our study, both treatments resulted in significant PD reduction and CAL gain, that extended in the supra-alveolar component, without differences with the use of BS. Both treatments resulted in soft tissue preservation. However, the addition of BS may improve interdental papillary tissue. Clinical relevance NIPSA, with or without bone substitutes, resulted in significant periodontal improvement, with soft tissue preservation in isolated, deep non-contained periodontal defects. The application of bone substitutes may provide interproximal soft tissue gain. Clinical trial registration Clinicaltrials.gov: NCT04712630.

Efficacy of biologics for the treatment of periodontal infrabony defects: An American Academy of Periodontology best evidence systematic review and network meta‐analysis

“…Figure 2 displays the relationships between the existing treatment arms (e.g., xenogeneic BG + EMD) from which the additive model was based upon. One‐hundred and twenty‐two treatment arms employed EMD 13 , 18,19,39,49,50,67,70,73,75–77,79,82,84–86,89,90,93,94,96–99,102,105–109 , 112–116,121–123,125,126,130,136–138,140–142,146,151,153,156–158,160,167–169,175 , 177,178,180,182–195,200–202,205–207,209–212 ,. 12 used rhPDGF‐BB 17,129,133,139,148,152,155,181 , 43 included PRF 19,71,72,74,78,80,81,83 , 88,91,92,103,110,115,120,131,144,145,149,150,154,162–165,170–174,196–198,203,204 , and 31 used PRP 68,87,95,100,101,117–119,124,127,128,132,134,135,143,147 , 159,161,166,173,174,179,199 .…”

“…The outcomes of flap procedures alone were reported in 54 study arms 18,39,49,70,72,74,76,78,80 , 82,84,86,87,89–92,94,105–109,113,121,128,131,149,152,158,163,164,169–173,175,177 , 178,190,195,198,200,203–205,210,212 . A total of 88 studies utilized BGs 17,19,49,50,67–71,75–78,80,81,83,84,86–88,91,94,95,97–102,104,110–112 , 114,116–120,122–124,126,127,129,130,132–135,137–148,150,153–157,159,161,164,166 , 167,170,174,179–181,187,192,193,196,197,199,206,208,209,211 , with 7 having utilized an autogenous BG 19,70,110,114,119,150,209 , 16 an allograft 67–69,77,78,81,88,116,123,124,135,147,156,157,166,197 , 28 a xenograft…”

Comparison between conventional and micro-assisted periodontal surgery

“…The primary difference/variable from the conventional approach was that microsurgical technology increased visual and tactile perception. [ 35 36 37 ] The coarseness of most surgical manipulations is revealed when periodontal surgery is studied under a microscope. Tissue handling that appears to be delicate turns out to be gross crushing and tearing.…”

Clinical and patient‐reported outcomes of tissue engineering strategies for periodontal and peri‐implant reconstruction

“…153,162,211,224,240 When tissue engineering strategies were tested against biologic agents alone for the treatment of infrabony defects, nine studies exhibited significantly higher outcomes in the tissue engineering strategy group, and another nine trials showed similar results. 155,162,180,187,205,210,212,221,235 Regarding furcation defects, two studies did not observe benefits in favor of tissue engineering strategies compared with conventional treatments, 220,223 but one trial obtained a statistically significantly superior clinical attachment level gain and pocket depth reduction after 1 year for mandibular furcations treated with tissue engineering strategies compared with guided tissue regeneration and flap alone. 185 The tissue engineering strategy group was also the treatment with the highest number of cases presenting complete closure of the furcation defect at 1 year.…”

“…I, J, Flap closure. K, L, Clinical and radiographic outcomes at the 11-year follow-up 48,251,[151][152][153][158][159][160]1,[193][194][195][212][213][214][215][216][217][218][240][241][242][243]67-69 54 trials were as signed an unclear risk of bias, 31,33,61,63,64,71,79,87,101,161,163, 172,174,175, 178,179,181,183,185,192,198,208, 209,227,230,231,234,235,242,243,246,148-150,154-157, 166-169,201-205,219-221,223-226 and the remaining seven studies showed a high risk of bias. 171,184,196,236,237,249,250 1.…”