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Year : 2011  |  Volume : 22  |  Issue : 3  |  Page : 391-395
Assessment of combination techniques in enhancing the regenerative potential of tricalcium phosphate graft in treatment of infrabony periodontal defects

1 Department of Periodontics, Chandra Dental College and Hospital, Safedabad, Barabanki, India
2 Department of Pedodontics and Preventive Dentistry, Chandra Dental College and Hospital, Safedabad, Barabanki, India
3 Department of Periodontics, Faculty of Dental Sciences, Chhatrapati Shahuji Maharaj Medical University, (upgraded, King George's Medical University), Lucknow, Uttar Pradesh, India

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Date of Submission10-May-2010
Date of Decision20-Aug-2010
Date of Acceptance29-Oct-2010
Date of Web Publication3-Nov-2011


Aims: The purpose of the present study was to evaluate and compare the clinical outcome of infrabony defects following reconstructive surgery with the use of tricalcium phosphate (TCP) alone; TCP and citric acid (CA) root conditioning; and TCP, CA, and oxidized regenerated cellulose (ORC) membrane.
Materials and Methods: Thirty-nine systemically healthy subjects with vertical infrabony defect were initially selected based on intraoral periapical radiographs and clinical examination to record probing pocket depth (PPD) and clinical attachment level (CAL). Only 21 defects revealed two-walled configuration on surgical debridement. These defects were selected and randomly allotted to the study groups. Group 1 defects were treated with TCP, group 2 with TCP+CA, and group 3 with TCP+CA+ORC. PPD, CAL, defect depth (DD), and level of alveolar crest (AC) were evaluated at the time of initial surgery and after 6 months at surgical re-entry. These measurements were utilized to calculate PPD reduction, CAL gain, defect fill (DF), %defect fill (%DF), and crestal resorption (CR).
Statistical Analysis: A paired t-test was used for assessing changes in each group. Unpaired t-test was used for intergroup comparisons.
Results: All three groups showed statistically significant PPD reduction, CAL gain, DF, and %DF, but insignificant CR at the end of 6 months. On intergroup comparison, no statistically significant differences were noted between the groups for all the parameters.
Conclusion: Efficacy of combination techniques using TCP+CA; TCP+CA+ORC in treatment of periodontal infrabony defects is at least equal to that of TCP alone.

Keywords: Citric acid, combination techniques, oxidized regenerated cellulose, tricalcium phosphate

How to cite this article:
Saini A, Singh M, Lal N, Dixit J. Assessment of combination techniques in enhancing the regenerative potential of tricalcium phosphate graft in treatment of infrabony periodontal defects. Indian J Dent Res 2011;22:391-5

How to cite this URL:
Saini A, Singh M, Lal N, Dixit J. Assessment of combination techniques in enhancing the regenerative potential of tricalcium phosphate graft in treatment of infrabony periodontal defects. Indian J Dent Res [serial online] 2011 [cited 2022 Dec 1];22:391-5. Available from:
The ultimate goal of periodontal therapy is to regenerate the lost periodontium. Several regenerative procedures have been described in the literature including open flap debridement with bone grafts or in combination with guided tissue regeneration and/or root conditioning. [1],[2],[3] These procedures have had different rates of success.

Often, sufficient autogenous bone is not available or would require additional surgical sites and chair time deemed unacceptable to the patient. [4] Allogenic bone provides an alternative to autogenous bones but the fear of disease transmission persists despite evidence to the contrary. [5],[6]

This fear has driven the market to produce clinically beneficial alternatives to allografts. Bone substitutes have filled this niche in periodontal practice, providing biocompatible defect fillers with variable biologic activity. [4]

The most widely used synthetic ceramic grafting materials are hydroxyapatite and tricalcium phosphate (TCP). TCP has been shown to stimulate bone formation, and is comparable or in most cases superior in this regard to hydroxyapatite. [7] TCP in humans has shown pocket reduction, gain in clinical attachment, and bone fill at re-entry. [8],[9],[10]

Good results in terms of gain of new attachment, [11],[12],[13],[14] accelerated healing and new cementum formation [15] were reported using citric acid (CA) conditioning of root surfaces.

Oxidized regenerated cellulose (ORC) membrane is readily available, easy to place, exhibits excellent hemostatic properties and aids in clot stabilization. It does not require any complex suturing techniques. [16],[17],[18],[19] It is a hemostatic dressing, which is commercially available in the form of a knitted fibrous mesh. It has been used in many studies as a barrier in the regenerative treatment of periodontal defects. [16],[17],[18],[19]

To our knowledge, the benefits brought about by adding ORC membrane and CA conditioning to TCP graft have not yet been tested. Therefore, the purpose of this study was to evaluate and compare the clinical outcomes of infrabony defects in terms of changes in probing pocket depth (PPD), clinical attachment level (CAL), defect fill (DF), % defect dill (%DF), and crestal resorption (CR), following reconstructive surgery with the use of TCP alone; TCP and CA; and TCP, CA, and ORC.

   Materials and Methods Top

Thirty-nine subjects with vertical infrabony defects in the age group ranging from 20 to 50 years irrespective of their sex were selected from Outpatient Department of Periodontics, U.P. King George's University of Dental Sciences, Lucknow.

Patient selection was based on a full diagnostic work-up that included intraoral periapical radiographs of areas of interest and clinical examination to record PPD and CAL. The purpose of the study and materials to be used were explained in detail to each patient. They were told that this was a human study and that a surgical re-entry would be necessary after 6 months to evaluate results. Each patient was required to sign an informed consent form. The patients selected were nonalcoholics, nonsmokers, and had no history of allergies or any systemic debilitating disease. All patients meeting the selection criteria were consecutively enrolled in this study from November 01, 2005 to January 01, 2008.

Prior to surgery, these patients were subjected to oral prophylactic procedures, occlusal equilibration if required and routine laboratory investigations; their oral hygiene status was reviewed till it was maintainable at a satisfactory level.

The procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 2000. All measurements were made by using an UNC-15 periodontal probe inserted through a groove cut in an acrylic stent that served as a fixed reference point. PPD and CAL were recorded immediately before surgery.

All patients were operated on under local anesthesia with a solution of 2% lignocaine with 1:80,000 adrenaline. A full thickness mucoperiostal flap was reflected. Vertical releasing incisions were performed when needed. A total of 21 defects demonstrated two-walled configuration and only these were included in the study. After thorough debridement and root planing the hard tissue measurements were made from the cemento enamel junction (CEJ) to the base of defect (BD) to evaluate the defect depth (DD), from CEJ to alveolar crest (AC) to evaluate level of AC, and from AC to BD [Figure 1].
Figure 1: Infrabony defect depth during initial surgery

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The present study was a randomized, controlled trial. Allotment of defects to one of the three groups mentioned below was made at the time of each surgical procedure after defect debridement.

Group 1: the defects were treated with TCP (PD VitalOS Cement, Produits Dentaires SA, Switzerland) alone placed in a doughy consistency into the defect in increments and packed to place with a sterile curette or a cotton pellet moistened in sterile saline.

Group 2: CA (pH 1.0) was applied to the root surfaces with the help of a camel hair brush. After 3 min of its application the defect was thoroughly irrigated by sterile saline to wash off CA. TCP in a doughy consistency was placed in the defect.

Group 3: CA and TCP were applied in the same manner as described for group 2, followed by the placement of ORC membrane (Surgicel® , Ethicon, Johnson and Johnson, USA) [Figure 2], [Figure 3] and [Figure 4].
Figure 2: Application of citric acid during initial surgery

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Figure 3: Placement of tricalcium phosphate during initial surgery

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Figure 4: Placement of oxidized regenerated cellulose barrier membrane during initial surgery

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Defects that were not included in the study did not receive the above treatment.

Flaps were repositioned and approximated with interrupted interdental sutures, using 3--0 black-braided silk. Periodontal dressing was applied over the sutured site.

Doxycycline was prescribed (100 mg twice on the first day, followed by 100 mg once daily) for 5 days. Nimesulide 100 mg twice daily and B-Complex, 1 capsule daily was also prescribed for 5 days. Subjects were asked to use 0.2% chlorhexidine mouthwash twice daily.

Seven days after surgery dressings and sutures were removed, the site was cleansed, and periodontal dressing was replaced, if needed. Subjects were recalled every 4 weeks for a period of 6 months for oral hygiene evaluation and prophylaxis.

All treated sites that were included in the present study were re-entered 6 months postoperatively and all parameters were re-recorded [Figure 5].
Figure 5: Infrabony defect depth during re-entry surgery

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Arithmetic determinations derived from the surgical measurements were calculated as follows:

The three treatment modalities were statistically compared. The mean scores and standard deviations were calculated for all parameters. The baseline and 6-month values were compared for changes that occurred over time, i.e., PPD reduction, CAL gain, DF, %DF, and CR. A paired t-test was performed to establish differences between baseline and re-entry measurements within each group. An unpaired t-test was utilized to evaluate differences between treatment groups. P≤0.05 was considered statistically significant.

   Results Top

Analysis of data within a particular treatment modality revealed statistically significant PPD reduction, CAL gain, DF, and %DF; but, insignificant CR for all the three groups [Table 1] and [Table 2]. Thus, there was a positive response to therapy for all three treatment modalities. There were no significant differences among the three treatment modalities with respect to PPD reduction, CAL gain, DF, % DF, and CR [Table 3]. However, the mean values for PPD reduction, CAL gain, DF and %DF were greatest for group 3, followed by group 2, and were least for group 1 [Table 2]. Moreover, groups 2 and group 3 had similar average CR, which was less than that of group 1 [Table 2].
Table 1: Mean clinical parameters for groups 1-3 at baseline and 6 months expressed in millimeters (mean±standard deviation)

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Table 2: Changes in clinical parameters over 6 months period expressed in millimeters (mean±standard deviation) and their significance for groups 1-3

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Table 3: Intergroup comparisons for changes in clinical parameters over 6-month duration

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   Discussion Top

Statistical analysis of this experiment found no significant difference between the three groups with regard to outcome of treatment while all groups demonstrated an overall significant improvement in all clinical parameters except CR.

All patients participating in this study tolerated the surgical procedures well. Some treated sites showed negligible inflammatory response which subsided after maintenance of proper oral hygiene.

Six-month surgical re-entry procedures were performed to allow for the visualization of the treated sites. In many studies surgical re-entry procedures have been performed for a 6-month period. [20],[21] However, bone remodeling may occur up to 2 years after grafting. [22] The histological method was not attempted due to ethical reasons. [23]

The results of this study with regard to the mean PPD reduction, CAL gain, and DF for group 1 compare favorably to those obtained by Snyder et al. [8] . They [8] reported an average PPD reduction of 3.6 mm, CAL gain of 2.7 mm, and DF of 2.8 mm. However, they performed surgical re-entry procedures at 18 months and included crestal, furcation, 1-wall and 2-wall defects in their study. Baseline parameters were not discussed in their study so they cannot be compared.

Reports from a recent study [24] claimed that implantation of granular beta-TCP in very advanced combined 1- and 2-wall intrabony defect at teeth scheduled for extraction due to periodontitis resulted in a mean PPD reduction of 6.2 mm, mean CAL gain of 5.0 mm, and mean bone formation of 1 mm in 6 months. However, average baseline PPD of their study was 10.8 mm which was much more than that of group 1 of the present study. Moreover their results were based on both clinical and histological evaluations. Our investigations revealed a mean percentage defect fill of 45.39% in group 1. Lately, surgically created defects treated with beta-TCP in animals showed a mean percentage of new bone regeneration of 40.31%. [25] The average CR for group 1 was -0.43 mm. To the best of our knowledge, CR that occurs after treatment of defects with TCP had not been discussed in the past.

Bunyaratavej et al. [1] and Chen et al. [2] reported that bone replacement grafts when utilizing barrier membranes appear to improve the clinical results in furcation, but not in intrabony defects. They also concluded that no additional improvement occurs in clinical conditions when citric acid treatment is used in conjunction with surgical procedures either without or in combination with osseous grafts and GTR techniques in terms of PPD reduction, CAL gain, DF, and CR.

Contrary to our observations, Reynolds [3] stated that bone grafts in combination with barrier membranes increase clinical attachment level and reduce probing depth compared to graft alone.

The defects were allotted to the groups by a dice toss during surgery therefore the mean baseline parameters for all the three groups could not be similar. This is a limitation of the present study which could have affected the results.

It should be noted that differences in healing patterns, microbial pathogens, study design, patient population, measurement techniques, and human defect variations make it difficult to compare clinical results. [20] Additionally, different TCP products were used in the various studies, and it is well known that the in vivo performance of bioceramics is related to the chemistry, porosity, density, and pore interconnectivity of the specific product. [26] Moreover, different methods like clinical, histological, and radiographic were used in various studies for assessing the outcomes of treatments. This could also be a reason for differences in results. It is also important to emphasize that a limited number of subjects were taken in this study. According to Gunsolly et al., [27] much larger sample sizes are required to demonstrate statistically significant differences.

In order to establish the efficacy of combination techniques using TCP graft, ORC membrane and CA conditioning, long-term controlled studies and histological evidence of regeneration are essential prerequisites.

   References Top

1.Bunyaratavej P, Wang HL. Collagen membranes: a review. J Periodontol 2001;72:215-29.  Back to cited text no. 1
2.Chen CC, Wang HL, Smith F, Glickman GN, Shyr Y, O'Neal RB. Evaluation of a collagen membrane with and without bone grafts in treating periodontal intrabony defects. J Periodontol 1995;66:838-47.  Back to cited text no. 2
3.Reynolds MA, Aichelmann-Reidy ME, Branch-Mays GL, Gunsolley JC. The efficacy of bone replacement grafts in the treatment of periodontal osseous defects. A systematic review. Ann Periodontol 2003;8:227-65.  Back to cited text no. 3
4.Aichelmann-Reidy ME, Yukna RA. Bone replacement grafts. The bone substitutes. Dent Clin North Am 1998;42:491-503.  Back to cited text no. 4
5.Buck BE, Malinin TI, Brown MD. Bone transplantation and human immunodeficiency virus. An estimate of risk of acquired immunodeficiency syndrome (AIDS). Clin Orthop Relat Res 1989;240:129-36.  Back to cited text no. 5
6.Mellonig JT, Prewett AB, Moyer MP. HIV inactivation in a bone allograft. J Periodontol 1992;63:979-83.  Back to cited text no. 6
7.Fetner AE, Hartigan MS, Low SB. Periodontal repair using PerioGlas in nonhuman primates: clinical and histologic observations. Compendium 1994;15:932, 935-8.  Back to cited text no. 7
8.Snyder AJ, Levin MP, Cutright DE. Alloplastic implants of tricalcium phosphate ceramic in human periodontal osseous defects. J Periodontol 1984;55:273-7.  Back to cited text no. 8
9.Nery EB, Lynch KL. Preliminary clinical studies of bioceramic in periodontal osseous defects. J Periodontol 1978;49:523-7.  Back to cited text no. 9
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12.Crigger M, Bogle G, Nilvéus R, Egelberg J, Selvig KA. The effect of topical citric acid application on the healing of experimental furcation defects in dogs. J Periodontal Res 1978;13:538-49.  Back to cited text no. 12
13.Nilvéus R, Bogle G, Crigger M, Egelberg J, Selvig KA. The effect of topical citric acid application on the healing of experimental furcation defects in dogs. II. Healing after repeated surgery. J Periodontal Res 1980;15:544-50.  Back to cited text no. 13
14.Nalbandian J, Cote N. Direct histological comparison of periodontal wound healing in the beagle dog with and without citric acid conditioning. J Periodontal Res 1982;17:552-62.  Back to cited text no. 14
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17.Galgut PN. Oxidized cellulose mesh. I. Biodegradable membrane in periodontal surgery. Biomaterials 1990;11:561-4.  Back to cited text no. 17
18.Galgut PN. A technique for treatment of extensive periodontal defects: a case study. J Oral Rehabil 1994;21:27-32.  Back to cited text no. 18
19.Galgut PN. Radiographic evidence of bone regeneration using oxidized cellulose mesh as a bioabsorbable membrane: some case studies. Periodontal Clin Investig 1996;18:22-5.  Back to cited text no. 19
20.Froum SJ, Coran M, Thaller B, Kushner L, Scopp IW, Stahl SS. Periodontal healing following open debridement flap procedures. I. Clinical assessment of soft tissue and osseous repair. J Periodontol 1982;5:8-14.  Back to cited text no. 20
21.Hutchens LH Jr. The use of a bovine bone mineral in periodontal osseous defects: case reports. Compend Contin Educ Dent 1999;20:365-8.  Back to cited text no. 21
22.Hiatt WH, Genco RJ. Regenerative therapy in periodontics. In: Genco RJ, Goldman HM, Cohen DW, editors. Contemporary periodontics. 7 th ed. St. Louis, The CV Mosby Co: 1990. P. 597.  Back to cited text no. 22
23.Mellado JR, Salkin LM, Freedman AL, Stein MD. A comparative study of ePTFE periodontal membranes with and without decalcified freeze-dried bone allografts for the regeneration of interproximal intraosseous defects. J Periodontol 1995;66:751-5.  Back to cited text no. 23
24.Stavropoulos A, Windisch P, Szendröi-Kiss D, Peter R, Gera I, Sculean A. Clinical and histologic evaluation of granular Beta-tricalcium phosphate for the treatment of human intrabony periodontal defects: a report on five cases. J Periodontol 2010;81:325-34.  Back to cited text no. 24
25.Podaropoulos L, Veis AA, Papadimitriou S, Alexandridis C, Kalyvas D. Bone regeneration using beta-tricalcium phosphate in a calcium sulfate matrix. J Oral Implantol 2009;35:28-36.  Back to cited text no. 25
26.LeGeros RZ, Daculsi G, LeGeros JP. Bioactive bioceramics. In: Pietrzak W, editor. Musculoskeletal Tissue Regeneration. Totowa, NJ: Human Press; 2009. P. 153-81.  Back to cited text no. 26
27.Gunsolley JC, Elswick RK, Davenport JM. Equivalence and superiority testing in regeneration clinical trials. J Periodontol 1998;69:521-7.  Back to cited text no. 27

Correspondence Address:
Ashish Saini
Department of Periodontics, Chandra Dental College and Hospital, Safedabad, Barabanki
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-9290.87059

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1], [Table 2], [Table 3]

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