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ORIGINAL ARTICLE
Year : 2015  |  Volume : 4  |  Issue : 4  |  Page : 229-235

Clinical and radiographic evaluations of porous hydroxyapatite as bone graft material in the treatment of interproximal vertical defects


1 Department of Periodontics, Government Dental College, Rajiv Gandhi Institute of Medical Sciences (RIMS), Kadapa, India
2 Department of Periodontics, Sri Sai College of Dental Surgery, Vikarabad, Telangana, India
3 Department of Periodontics, CKS Teja Institute of Dental Sciences, Tirupati, Andhra Pradesh, India
4 Department of Periodontics, College of Dental Sciences, Davanagere, Karnataka, India

Date of Web Publication14-Dec-2015

Correspondence Address:
Dandu Subramanyam Madhu Babu
Department of Periodontics, Government Dental College, Rajiv Gandhi Institute of Medical Sciences (RIMS), Kadapa, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2277-8632.171707

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  Abstract 

Background: Periodontal regeneration has been the goal over the past few years in the treatment of various periodontal defects. Various traditional surgical and nonsurgical approaches were found to produce the minimal amount of new periodontal attachment apparatus. It was further suggested that the addition of various graft materials might increase the amount of new bone, periodontal ligament, and cementum generated. Hence, this clinical study was undertaken to evaluate the efficacy of porous hydroxyapatite in the treatment of interproximal vertical bony defects in human beings as a regenerative implant material.
Materials and Methods: A total of 16 sites from eight patients in the age group of 30-60 years were selected. Out of the two sites from each patient, one was control site-flap surgery without porous hydroxyapatite graft material and the other was experimental site-flap surgery with porous hydroxyapatite graft material. At 3 months, 6 months, and 9 months postoperatively, each site was subjected to clinical parameters such as pocket depth, attachment gain, gingival recession, and osseous fill.
Results: Significant mean attachment gain was observed at 6 months and 9 months after surgery. The mean original defect was significant at 3 months and 6 months postsurgically. Mean percentage fill was significant at 3 months postsurgically. All other parameters were nonsignificant.
Conclusion: Radiographic assessment showed a greater defect fill at the grafted site indicating the superiority of grafting procedure to nongraft procedure. Hence, porous hydroxyapatite crystals are an effective graft material in elimination of interproximal vertical defects.

Keywords: Interproximal vertical defects, periodontal regeneration, porous hydroxyapatite crystals


How to cite this article:
Babu DS, Reddy KV, Deepa A, Patil S, Vandana, Nagireddy RR. Clinical and radiographic evaluations of porous hydroxyapatite as bone graft material in the treatment of interproximal vertical defects. J NTR Univ Health Sci 2015;4:229-35

How to cite this URL:
Babu DS, Reddy KV, Deepa A, Patil S, Vandana, Nagireddy RR. Clinical and radiographic evaluations of porous hydroxyapatite as bone graft material in the treatment of interproximal vertical defects. J NTR Univ Health Sci [serial online] 2015 [cited 2020 Nov 27];4:229-35. Available from: https://www.jdrntruhs.org/text.asp?2015/4/4/229/171707


  Introduction Top


Periodontal disease is one of the most prevalent diseases worldwide. The most serious consequence is the destruction of the tooth supporting structures such as periodontal ligament, cementum, and the alveolar bone resulting in the eventual loss of the tooth. [1] Reducing pathologically deepened probing depths is a laudable goal. When and how to best approach these bacterial sumps is the quandary; while closed procedures are effective in controlling some bacterial sumps, in many cases surgery is warranted.

Over the last few years, the emphasis of surgical procedures has shifted more and more toward regeneration with the idea that this would increase the longevity of the dentition. This trend started when traditional surgical and nonsurgical approaches were found to produce minimal amount of new periodontal attachment apparatus. Specifically, closed subgingival scaling and root planning in humans has been shown to produce regeneration. The same was true for surgery using a replaced flap. It was subsequently suggested that the addition of various graft materials might increase the amount of new bone, periodontal ligament, and cementum generated. Various reports [2],[3] on the filling in of bone defects after periodontal surgery suggest a considerable degree of bone fill and other reports have found residual bone defects after surgery. The unpredictability of filling in of bone defects after periodontal surgery has resulted in the investigation of various types of bone grafting materials and of synthetic implant materials. The implantation of various materials has been used in an attempt to counteract progression of the disease. The best results in the regeneration of root cementum, alveolar bone, and a functional periodontal ligament have been achieved using autologous bone transplants although resorption and ankylosis following this technique have been reported. The use of allograft in osseous defects has been described but there is a danger of transmission of infection and graft rejection. However, xenografts are generally not accepted for human use due to possible immunologic complications.

For this reason, the search for a substitute material for periodontal surgery has intensified in the recent years. In the course of this search, alloplastic materials used recently to reconstruct osseous periodontal defects include ceramics, collagen, and polymers. Although experiments have been conducted with various therapeutic approaches, current scientific interest in alloplastic replacements is focused primarily on calcium phosphate ceramics. Among calcium phosphate ceramics, hydroxyapatite and tricalcium phosphate have been tried by a number of investigators. Case reports [4],[5],[6],[7],[8] have already shown encouraging results from a variety of hydroxyapatite ceramic materials and have evaluated the material on clinical, radiographic, reentry, and histological procedures.

Hydroxyapatite ceramics come very close to fulfilling the criteria for the ideal bone substitute. The most important feature of hydroxyapatite in contrast to other inorganic materials is its unique biologic properties as it consists of only calcium and phosphate, which are found everywhere in the human organs and thus, no toxicity or defense reaction is expected. The biocompatibility, tolerance, and biologically active property of hydroxyapatite make it an ideal bone substitute. Clinically, the two most widely clinically applied calcium phosphate ceramics are composed of either hydroxyapatite [(Ca 10 (Po 4 ) 6 (OH) 2 ] or tricalcium phosphate [Ca 3 (Po 4 ) 2 ]-hydroxyapatite, is the only calcium phosphate ceramic that has similar calcium to phosphate ratio to that of bone mineral.

Hence, this clinical study was undertaken to evaluate the efficacy of porous hydroxyapatite (Chitra granules) in the treatment of interproximal vertical bony defects in human beings as a regenerative implant material.


  Materials and Methods Top


A total of 16 sites from eight patients (two sites per each patient) in the age group of 30-60 years, including both males and females, who presented to the outpatient wing of the periodontics department were selected. Informed consent was obtained from the subjects and the protocol was approved by the ethics committee of our institution. This study was conducted with a split-mouth design. The inclusion criteria required two interproximal sites appropriately separated with probing depth ≥6 mm clinically and an angular defect found radiologically in each patient. Out of the two sites, one was control site-flap surgery without porous hydroxyapatite graft material (Chitra granules) and the other was experimental site-flap surgery with porous hydroxyapatite graft material (Chitra granules).

On the screening visit, clinical parameters such as pocket depth and attachment loss for each selected site were recorded using UNC-15 graduated periodontal Probe (Hu-Friedy). Patients were subjected to intraoral periapical (IOPA) radiographs to measure the depth of osseous defect and impressions were made for the fabrication of stent. At 3 months, 6 months, and 9 months postoperatively, each site was subjected to clinical parameters such as pocket depth, attachment gain, gingival recession, and osseous fill (radiographically).

Surgical procedure

The periodontal flap surgery was carried out under regional infiltration of local anesthesia using 2% lignocaine with adrenaline 1:80,000. Each defect site (control and experimental) was exposed by reflection of the mucoperiosteal flap. The defect was cleared of granulation tissue and the exposed root surface thoroughly planed to a smooth hard surface. The surgical area was then washed with normal saline and carefully inspected for any remaining granulation tissue or deposits. In the experimental site, after root planning the root surfaces were conditioned with tetracycline hydrochloride. Then Chitra granules were transferred from the sterile vial to a dappen dish and moistened with sterile saline, which was placed into the vertical defects to the approximate level of the crest of the remaining osseous walls.

The operative sites were closed with 3-0 black silk interrupted sutures and protected with a noneugenol dressing. Antibiotics were prescribed for 1 week. At 1 week following surgery, the dressing and sutures were removed.

Clinical assessments

The customized thermoplastic occlusal stent was placed on each defect site. Pocket measurements using UNC-15 graduated periodontal probe, attachment gain, and gingival recession measurements were repeated similar to the previous presurgical measurement procedures.

Radiographic measurements

IOPA radiographs were taken for each site before surgical procedure and at intervals of 3 months, 6 months, and 9 months, respectively, using paralleling cone technique.

Measurement of osseous defects

Radiograph of each site was digitized using a flatbed scanner with a scanning resolution of 600 dpi. (UMAX - ASTRA 1220S-Vue Scan-Hamrick Software, USA). The scanned images, stored in the Joint Photographic Experts Group (JPEG) format, were transferred to COREL DRAW (Corel Corporation of Ottawa, Canada). This software allows superimposition of a 1-mm grid over the radiographic image. For measurement, connector line tool was used. Usage of this tool enables a line to be drawn from cementoenamel junction (CEJ) to the base of the defect. The length of the line is displayed in the size property box of the software. The software then displays the distance between these two points. The same procedure is then repeated to obtain the distance between CEJ and alveolar crest. On subtracting the two measurements, the depth of the osseous defect is obtained.

Statistical analysis

Data analyses were performed using the statistical package SPSS (SPSS Inc., Microsoft Corp., Chicago, USA). The statistical significances of pocket depth, attachment gain/loss, gingival recession, and radiographic measures before and after 3 months, 6 months, and 9 months of treatment were analyzed using Wilcoxon signed-ranks test. Changes in soft tissue were analyzed by paired t test (within groups). Intergroup comparison of soft tissue changes was carried out by unpaired t test.


  Results Top


The values of mean pocket depth reduction when compared between the control group and experimental group at 3 months, 6 months, and 9 months after surgery was were not statistically significant [Table 1]. On comparing the mean attachment level gain between the control group and experimental group, the values at 6 months and 9 months after surgery were statistically significant. The value at 3 months after surgery was not statistically significant [Table 2]. On comparing the mean gingival recession between the control group and experimental group, the values at 3 months, 6 months, and 9 months after surgery were not statistically significant [Table 3]. When the mean of original defect fill was compared between the control group and experimental group, the t values at 3 months and 6 months after surgery were statistically significant. The t value at 9 months after surgery was not statistically significant. On comparing the mean percentage of original defect between the control group and experimental group, the t value at 3 months after surgery was statistically significant, whereas the t values at 6 months and 9 months postsurgery were not statistically significant. On comparing the mean change in alveolar crest level between the control group and experimental group, the t values at 3 months, 6 month, and 9 months after surgery were not statistically significant. On comparing the mean percentage change in alveolar crest height between the control group and experimental group, the t values at 3 months, 6 months, and 9 months after surgery were not statistically significant. On comparing the mean percentage of original defects resolved between the control group and experimental group, the t values at 3 months, 6 months, and 9 months after surgery were not statistically significant [Table 4],[Table 5] and [Table 6].
Table 1: Comparison of The Mean Values of Pocket Depth Between The Experimental Group And Control Group At The Baseline, 3 Months, 6 Months, And 9 Months After Surgery

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Table 2: Comparison of Mean Value of Attachment Gain/Loss Between The Experimental Group And Control Group At Baseline, 3 Months, 6 Months, And 9 Months After Surgery

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Table 3: Comparison of Mean Values of Gingival Recession Between The Experimental Group And Control Group At Baseline, 3 Months, 6 Months, And 9 Months After Surgery


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Table 4: Comparison of Mean Radiographic Changes Between the Experimental Group And Control Group at 3 Months after Surgery

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Table 5: Comparison of Mean Radiographic Changes Between The Experimental Group And Control Group 6 Months After Surgery

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Table 6: Comparison of Mean Radiographic Changes Between the Experimental Group and Control Group 9 Months After Surgery

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  Discussion Top


The reconstruction or restoration of osseous defects caused by inflammatory periodontal disease has long been a challenge in periodontics. Although many attempts have been made to regenerate alveolar bone support, predictable success has proved elusive.

Measuring the success in osseous grafting requires an analysis of the parameters to be used in comparative studies. Though the ultimate test for regeneration is histological assessment, this measurement is often prevented in human trials by ethical considerations. When the clinical parameters of various studies [6],[10] are compared, variables such as the magnitude and anatomy of presurgical osseous defects and the length of time for postsurgical follow-up must be taken into consideration.

In the present study, pocket depth reduction was observed in both the control group and experimental group at 3-month, 6-month, 9-month intervals with P < 0.64, P < 0.45, and P < 0.30, respectively, which were not statistically significant. However, at all levels in the experimental group, the values were higher than the control group. This finding was in accordance with that of Rabalais et al. [7] and Krejci et al. [4]

In present study, the clinical attachment gain was observed in both the control group and the experimental group. The values at 6 months and 9 months were statistically highly significant (P < 0.05 and P < 0.04, respectively). This finding was in accordance with that of Yukna et al., [11] Kenney et al., [5] and Galgut et al. [12] The value at 3 months after surgery was not statistically significant (P < 0.01). This finding was in accordance with that of Rabalais et al. [7]

Gingival recession was observed in both groups in the present study. However, the gingival recession observed was greater in the control group than the experimental group. But on comparison between the groups, the value was not significant at all levels of postsurgery (P < 0.33). Similar findings were reported in the studies by Rabalais et al., [7] and Kenney et al. [6]

In the majority of earlier studies, reentry measurements were made whereas only radiographic interpretation was used in the present study. The reentry procedure was not performed since it causes a degree of ethical concern and is usually not accepted by the patient. Furthermore, during second surgery, the new connective tissue attachment may be disturbed and replaced by a long junctional epithelium. Also, the problem of loss of the crestal alveolar bone following the procedure remains unresolved. Radiographic assessment provides the only noninvasive method for evaluating the changes in hard tissue. So, in the present study the hard tissue response was evaluated only by radiographic parameters without reentry procedure.

On comparing the postoperative mean defect fill between the experimental group and control group at 3 months and 6 months, the t values were 3.15 (P < 0.007) and 2.18 (P < 0.047), respectively, which were statistically significant. This was in accordance with the results of Yukna et al. [13] At 9 months after surgery, the t value was 1.76 (P < 0.12) that was not statistically significant. This was in accordance with the results of Krejci et al. [4]

On comparing the mean percentage fill of original defects between the control group and experimental group, the t value at 3 months after surgery was 2.37 (P < 0.032) that was statistically significant. The t values at 6 months and 9 months after surgery were 1.55 (P < 0.14) and 1.75 (P < 0.12), respectively, which were not statistically significant; this finding was in accordance with the result of Krejci et al. [4]

In the present study, the mean change in alveolar crest level in the experimental group was higher than the control group at all levels of postsurgery. These values were not statistically significant, which was in accordance with the results of Rabalais et al., [7] Kenney et al., [6] and Krejci et al. [4] Similarly, the mean percentage change in alveolar crest in the experimental group was higher than the control group but was not statistically significant. This was in accordance with the results of Rabalais et al., [7] Kenney et al., [6] and Krejci et al. [4]

In the experimental group, the percentage of defect resolution after 3 months, 6 months, and 9 months after surgery was 51.24 + 27.78, 30.89 ± 13.80, and 30.01 ± 21.12, respectively. In the control group, the percentage of defect resolution at 3 months, 6 months, and 9 months after surgery was 16.76 ± 18.22, 17.79 ± 21.40, and 24.26 ± 79.56, respectively. The mean percentage of defect resolution in the experimental group was greater than the control group. The t values were 2.76 (P < 0.015), 1.68 (P < 0.14), and 0.58 (P < 0.58) at all levels of postsurgery. The values were not statistically significant; similar findings were reported in the studies by Rabalais et al., [7] and Meffert et al. [14]

Clinically, the soft tissue response to Chitra porous hydroxyapatite is better than the control group. Out of these clinical parameters, only attachment gain is found to be statistically significant on comparison. Hence, the soft tissue response is almost equivocal in both the groups. However, these changes do not reflect the clinical assessment of hard tissue changes.

On analyzing the hard tissue changes, the mean values of the parameters such as amount of defect fill, percentage of defect fill, percentage of defect resolution, and percentage of crestal resorption were found to be greater in the experimental group than the control group but were not statistically significant. On comparison of 0-9 months after surgery, greater values in the experimental group suggest that the implantation of Chitra porous hydroxyapatite in periodontal defects leads to better defect fill than the debridement alone. Statistically, the result may not be significant as a large sample is required for analysis. The radiographic finding is not reliable numerical data. The reason behind this reticence was the difficulty to get an absolutely reproducible radiograph in all cases and the interpretation was further complicated by the fact that the image of the implant was similar in density to the surrounding bone.


  Summary and Conclusion Top


The following conclusions were drawn from the above study. Porous hydroxyapatite (Chitra granules) implant material was biologically acceptable, with good handling properties. Pocket depth reduction and attachment level gain were excellent and there was also a lesser amount of gingival recession in the grafted sites. Radiographic assessment showed greater defect fill at grafted sites indicating the superiority of grafting procedure to nongraft procedure. Hence, Chitra porous hydroxyapatite crystals are an extremely effective graft material in the elimination of interproximal vertical defects. However, further studies should be directed toward long-term postsurgical evaluation for further confirmation of periodontal regeneration. Reentry and histologic evidences are necessary to support the findings and also to prove the osteoconductive/osteogenic potential of the material.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Galgut PN, Waite IM, Brookshaw JD, Kingston CP. A 4-year controlled clinical study into the use of a ceramic hydroxylapatite implant material for the treatment of periodontal bony defects. J Clin Periodontol 1992;19:570-7.   Back to cited text no. 12
    
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Yukna RA, Harrison BG, Caudill RF, Evans GH, Mayer ET, Miller S. Evaluation of durapatite ceramic as an alloplastic implant in periodontal osseous defects. II. Twelve month reentry results. J Periodontol 1985;56:540-7.  Back to cited text no. 13
    
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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