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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 13  |  Issue : 4  |  Page : 213-216

Demineralized freeze-dried bone allograft in treatment of interproximal vertical defect - a clinical report


1 Department of Periodontology, Saraswati Dental College and Hospital, Lucknow, India
2 Department of Conservative Dentistry and Endodontics, Saraswati Dental College and Hospital, Lucknow, India
3 Department of Periodontics, Azamgarh Dental College, Azamgarh, Uttar Pradesh, India
4 Department of Conservative Dentistry and Endodontics, Mithila Minority Dental College and Hospital, Darbanga, Bihar, India

Date of Submission27-Jun-2016
Date of Acceptance21-Aug-2016
Date of Web Publication14-Dec-2016

Correspondence Address:
Ruchi Srivastava
Department of Periodontology, Saraswati Dental College and Hospital, Lucknow 227105, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-8574.195719

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  Abstract 

Bone destruction due to periodontal disease is one of the factors responsible for loss of teeth. The ultimate goal of periodontal therapy is predictable regeneration of lost periodontal tissue including bone defects. Various bone graft materials have been used for periodontal regeneration, which include autogenous grafts, allografts, xenografts, and synthetically produced ones. Amongst allogenic bone grafts, demineralized freeze-dried bone allograft (DFDBA) is most commonly used. All the bone allografts are osteoconductive, but DFDBA also provide an osteoinductive effect. DFDBA has been successfully used to reconstruct intraosseous periodontal defects and furcation defects. This case report describes the management of an intrabony defect in a maxillary left canine where the osseous defect included loss of buccal wall extending up to the periapical region. This localized periodontitis was successfully treated with periodontal regenerative technique using DFDBAs. DFDBA was used because it contains BMP, which induces new bone formation during the healing process. After 1-year follow-up of treatment, the tooth was functional without any signs and symptoms. Clinical and radiographic changes revealed healthy periodontal support.

Keywords: allograft, demineralized freeze-dried bone allograft, periodontal regeneration


How to cite this article:
Srivastava R, Verma PK, Tripathi V, Tripathi P. Demineralized freeze-dried bone allograft in treatment of interproximal vertical defect - a clinical report. Tanta Dent J 2016;13:213-6

How to cite this URL:
Srivastava R, Verma PK, Tripathi V, Tripathi P. Demineralized freeze-dried bone allograft in treatment of interproximal vertical defect - a clinical report. Tanta Dent J [serial online] 2016 [cited 2023 Feb 3];13:213-6. Available from: http://www.tmj.eg.net/text.asp?2016/13/4/213/195719


  Introduction Top


The primary goal of periodontal treatment is to produce an environment that is conducive to oral health. Bone grafting is the most common form of regenerative therapy and many bone substitutes are available such as autografts, allografts, xenografts, and synthetic grafts. Although autogenous bone is still gold standard in bone regeneration procedures but due to its donor site morbidity and lesser quantity available, various other alternative products are preferred [1]. One of its commonly used substitute is allogenic bone graft. Studies by Urist [2], have shown that demineralization of bone results in enhanced osteogenic potential. Demineralized freeze-dried bone allografts (DFDBA) have been used extensively in periodontal therapy and have shown significant improvements in bone augmentation procedures [3].

All other bone allografts are osteoconductive, but DFDBA also provide an osteoinductive effect. It is used because it contains bone morphogenetic protein (BMP), which induces new bone formation during healing process [4]. DFDBA has its own limitations regarding availability of graft material, for which the operator has to depend upon a hospital source. Moreover, possibility of an immunological reaction and transmission of infective diseases are other disadvantages of DFDBA [5]. By treatment of cadaveric bone with viral particles and cortical bone procured from a donor who had died of AIDS with a viricidal agent and demineralization in HCl has been found to inactivate HIV [6]. This article presents a case report in which an intrabony defect in maxillary left canine was successfully treated with interdisciplinary approach, with combined endodontic treatment and DFDBA for bone regeneration.


  Case report Top


A 32-year-old female visited Department of Periodontology with complain of pus discharge from upper left canine from past 6 days. On periodontal examination, gingiva of 23 was inflamed and edematous, bleeding on probing, pus discharge from gingival sulcus area and pocket depth 10 mm was present on mesial aspect [Figure 1]. On hard tissue examination, tooth was sensitive to vertical percussion with grade-I mobility, and pulp vitality tests showed no response in 23. On radiographic examination a deep vertical defect was present on mesial aspect of 23 extending up to root apex [Figure 2]. Therefore, considering dental history, clinical tests and radiographs, the case was diagnosed as 'localized chronic periodontitis with combined periodontal-endodontic lesion'.
Figure 1:Preoperative

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Figure 2: Preoperative intraoral periapical radiograph

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A multidisciplinary approach involving endodontic and periodontal therapy was planned. After patient's consent phase-I periodontal therapy was done, followed by conventional root canal treatment. After re-evaluation of phase-I, periodontal surgery was planned. Under local anesthesia, mucoperiosteal flap was raised and abundant granulation tissue was observed with complete buccal dehiscence in 23 [Figure 3]. The root surfaces and apical area were thoroughly planed with help of curettes. After thorough root planing and apical curettage, this large osseous defect was filled with DFDBA (Tata Memorial Hospital, Mumbai, Maharashtra, India) covering the root surface [Figure 4]. Flap was repositioned and sutured with 3-0 silk nonresorbable interrupted sutures and periodontal pack was applied.
Figure 3: Flap reflected

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Figure 4: Demineralized freeze-dried bone allograft placed

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Postoperative instructions were given to the patient and analgesic (ibuprofen 400 mg, thrice daily) was prescribed for 3 days. Patient was instructed to use 0.2% of chlorhexidine mouth rinse for a week from second day after periodontal surgery. Patient was monitored on weekly schedule postoperatively, to ensure good oral hygiene in surgerized area. There were no postoperative complications with satisfactory healing [Figure 5]. Supportive periodontal maintenance at 3 months was prescribed to maintain periodontal health and to re-evaluate this area.
Figure 5: Postoperative

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Re-evaluation after 1 year, showed complete healing with healthy gingiva. Results were satisfactory, mobility was reduced to less than grade I, probing depth was minimal and patient was asymptomatic. The radiograph after 1-year follow-up, showed evidence of apparent bone fill with gain in periodontal support [Figure 6].
Figure 6: Follow-up intraoral periapical radiograph after 1 year

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  Discussion Top


Various treatment modalities have been advocated for regeneration of osseous defects. These include scaling and root planing, flap curettage, bone grafts, guided tissue regeneration, and use of enamel matrix proteins. Amongst bone grafts, although autogenous grafts are gold standard but the main advantage of allografts is that they eliminate the need for a donor site and also it can be used in large quantities, if required [7].

DFDBA is most commonly used because of the presence of BMP which facilitates new bone formation by allowing undifferentiated mesenchymal progenitor cells undergo phenotypic conversion to the osteoblasts. In this case, DFDBA was very well tolerated by the patient with no adverse effects such as periodontal abscess, inflammation, or allergic reaction in the treated surgical site. Although the clinical parameters, that is, probing pocket depth reduction, clinical attachment level gain and radiographic evidence of bone fill have proved to be consistent with the successful regenerative therapy. Schwartz et al. [8] have shown that there is a wide variety of DFDBA products on the market which have different inductive capabilities. These differences may be related to the origin and methods of preparation of DFDBA and if the preparation methods were the same in different bone banks, this would be due to individual donors' ages and sexes, disease and injury, medical treatment, or genetic differences.

Also, the variations of time between death and the bone extraction, may result in significant loss of the bone inductive ability. There are many differences in size and the surface shape of DFDBA particles that may affect their inductive ability [9]. Bone cells distinguish different surface shapes and roughness and this will lead to differences in phenotypic diversity.

At times the extent of osseous destruction can lead to complex pathological conditions involving the pulpal and periodontal tissues and can pose a challenge to the clinician for the diagnosis and clinical management [10].

As in the above mentioned case there was pulpal and periodontal involvement and hence this type of lesion requires both endodontic and periodontic treatment. Thus, careful evaluation of clinical signs and appropriate diagnostic tests are of paramount importance in order to prevent incorrect diagnosis and treatment.


  Conclusion Top


Advanced periodontal regeneration treatment modalities can help to increase new attachment when compared with debridement alone. However, because of the limited amount of intraoral donor bone, it is preferable to use DFDBA for the treatment of large intrabony defects with a predictable prognosis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Williams A, Szabo RM. Bone transplantation. Orthopaedics 2004; 27:488-495.  Back to cited text no. 1
    
2.
Urist MR. Bone histogenesis and morphogenesis in implants of demineralized enamel and dentin. J Oral Surg 1971; 29:88-102.  Back to cited text no. 2
    
3.
Aspriello SD, Ferrante L, Rubini C, Piemontese M. Comparative study of DFDBA in combination with enamel matrix derivative versus DFDBA alone for treatment of periodontal intrabony defects at 12 months post-surgery. Clin Oral Investig 2011; 15:25-32.  Back to cited text no. 3
    
4.
Vaziri S, Vahabi S, Torshabi M, Hematzadeh S. In vitro assay for osteoinductive activity of different demineralized freeze-dried bone allograft. J Periodontal Implant Sci 2012; 42:224-230.  Back to cited text no. 4
    
5.
Jindal V, Gill AS, Kapoor D, Gupta H. The comparative efficacy of decalcified allogenic bone matrix and intra-oral free osseous autografts in the treatment of periodontal intrabony defects. J Indian Soc Periodontol 2013; 17:91-95.  Back to cited text no. 5
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6.
Mellonig J, Prewett A, Moyer M. HIV inactivation in a bone allograft. J Periodontol 1992; 63:979-983.  Back to cited text no. 6
    
7.
Behfarnia P, Shahabooei M, Mashhadiabbas F, Fakhari E. Comparison of bone regeneration using three demineralized freeze-dried bone allografts: a histological and histomorphometric study in rabbit calvaria. Dent Res J 2012; 9:554-560.  Back to cited text no. 7
    
8.
Schwartz Z, Somers A, Mellonig JT, Carnes DL Jr, Dean DD, Cochran DL, et al. Ability of commercial demineralized freeze-dried bone allograft to induce new bone formation is dependent on donor age not but gender. J Periodontol 1998; 69:470-478.  Back to cited text no. 8
    
9.
Miron RJ, Bosshardt DD, Laugisch O, Dard M, Gemperli AC, Buser D, et al. In vitro evaluation of demineralized freeze-dried bone allograft in combination with enamel matrix derivative. J Periodontol 2013; 84:1646-1654.  Back to cited text no. 9
    
10.
Verma PK, Srivastava R, Gupta KK, Srivastava A. Combined endodontic - periodontal lesion: a clinical dilemma. J Interdiscip Dentistry 2011; 1:119-124.  Back to cited text no. 10
  Medknow Journal  


    Figures

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


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