Use of a
Bioactive Alloplast, in the Treatment of Human Periodontal
Osseous Defects - A Case Report
1. Dr. Suvarna Patil MDS
Prof. and Head,
Department of Periodontics,
KLE VK Institute of Dental Sciences, Belgaum
drsuvarnapatil@yahoo.co.in
2. Dr.
Harsha M B MDS
Assistant Prof.,
Department of Periodontics,
Dayanandasagar college of Dental Sciences, Bangalore
harshamb@yahoo.com
Dental Follicle -
The Monthly
E- Journal Of Dentistry Vol
- V I Number- I I I
July 2011
ISSN 2230 – 9489 (e)
Abstract
Periodontal diseases are a group of inflammatory diseases
mainly caused by bacteria and their products. The
pathological hallmark of periodontitis is the destruction of
the supporting structures of the teeth involved. One of the
biggest challenges remaining in dentistry is to predictably
regenerate the alveolar bone destroyed by periodontitis. The
osseous regenerative procedure shown in this case using a
bioactive glass alloplastic bone graft material,
demonstrated structurally and functionally stable
periodontium, both clinical and radiographically at the end
of 6 months follow up.
Key Words
Regenerative osseous surgery, bioactive glass, alloplastic
bone grafts
Introduction
Periodontal diseases are a group of inflammatory diseases
mainly caused by bacteria and their products. The
host response to bacteria and their products is mediated by
the production and release of local factors from
inflammatory cells, especially lymphocytes and monocytes, as
well as cells of mesenchymal origin, such as osteoblasts and
fibroblasts.1
Plaque and its associated bacteria, which populate the
periodontal pocket, release lipopolysaccharide and other
bacterial products to the sulcus, affecting both the immune
cells in the connective tissue, as well as the
osteoblasts. In the immune cells, these products induce
local factor production, including IL-1α, IL-1β,
IL-6, prostaglandin E2 and tumor
necrosis factor α. These factors increase osteoclast
formation and activation as well as inhibit osteoblast
function. The bacterial products also affect the osteoblasts
directly, inhibiting their function and inducing factor
production and release, eventually inducing pre-osteoclast
differentiation and osteoblast activation.1 The
processes of bone resorption and bone formation are
regulated by systemic hormones as well as local factors.
Changes in the normal balance of bone modeling and
remodeling causes bone loss. In periodontal disease, the
response of bone to local factors, produced by the
inflammatory process, changes the bone remodeling balance,
with a net effect of bone resorption and loss of attachment.
Bone replacement grafts are the
most widely used treatment options for the correction of
periodontal osseous defects.
Objectives of
periodontal bone
grafts2:
1) Probing depth reduction,
2) Clinical
attachment gain,
3) Bone fill of the
osseous defect
4) Regeneration of
new bone, cementum and periodontal ligament.
It has been proved that bone replacement grafts provide clinical
improvements in periodontal osseous defects compared with
surgical debridement alone. For the treatment of intrabony
defects, bone grafts have been found to increase bone level,
reduce crestal bone loss, increase clinical attachment
level, and reduce probing pocket depths compared with open
flap debridement procedures.3 Bone replacement
grafts include autografts, allografts, xenografts, and
alloplasts.
Autogenous bone grafts:
Due to their
osteogenic potential, autogenous bone grafts of extra- and
intraoral sources have been used in periodontal therapy.
Iliac grafts have been used fresh or frozen. Successful bone
fill has been demonstrated using iliac cancellous bone with
marrow in furcations, dehiscences, and intraosseous defects
of various morphologies. Iliac grafts have had only limited
use because of the difficulty in obtaining the graft
material, morbidity, and the possibility of root resorption.4
The maxillary tuberosity or a healing extraction site
is typically the donor choice for intraoral cancellous bone
with marrow grafts.
Allogenic bone
grafts: Allografts involve bone taken from one human for
transplantation to another. Iliac cancellous bone and
marrow, freeze-dried bone allograft (FDBA), and decalcified
FDBA are the types of bone allografts widely available.
Xenografts:
A xenograft (heterograft) is a graft taken from a donor of
another species and is referred to as anorganic bone.
Recently, concern about the risk of transmission of diseases
from bovine-derived products has arisen, hence the use of
these grafts are restricted.
Alloplasts: Alloplastic materials are synthetic, inorganic, biocompatible, or
bioactive bone graft substitutes. Alloplast materials are
believed to promote bone healing through osteoconduction.
Currently, six types of alloplastic materials are commercially
available: hydroxyapatite cement, nonporous hydroxyapatite,
porous hydroxyapatite, beta tricalcium
phosphate, polymethylmethacrylate/hydroxyethylmethacrylate (PMMA/
HEMA) calcium-layered polymer, and bioactive glass.
Case Report:
A male patient aged about 35 years reported to the
department of Periodontics, KLE VK Institute of Dental
Sciences, Belgaum, with a chief complaint of dull aching
pain in the lower left front tooth region since 3 weeks.
Patient gave a history of swelling in the gums in the same
region 6 months back which subsided on its own in about a
week’s time. On examination, a deep periodontal pocket
measuring about 7 mm was detected on the mesial aspect of
mandibular left canine tooth. The interdental papilla in
that region was soft and edematous with exudation from the
gingival crevice. An intraoral periapical radiograph showed
severe bone loss in the interproximal region between
mandibular left lateral incisor and canine teeth
(Figure 1). Medical history of
the patient was noncontributory. A regenerative osseous
surgical procedure was planned. The patient was informed
about the procedures and an informed consent obtained.
Scaling and root planning procedures were performed
following oral hygiene instructions. The patient review at 4
weeks follow up after phase I therapy, revealed improvement
in the consistency of the gingival, however there was no
reduction in the probing depth of the pocket. The planned
regenerative procedure was undertaken.

Figure 1: Interdental Bone loss seen between lateral incisor
and canine
Surgical
technique:
The surgical area was prepared with adequate local
anesthesia using 2% Lignocaine HCl containing 1:80,000
adrenaline. An envelope flap was raised using the crevicular
incision extending from mesial aspect of mandibular right
canine to distal aspect of mandibular left first premolar.
Thorough debridement of granulation tissue revealed a
3-walled intra bony defect between mandibular left lateral
incisor and canine teeth (Figure 2).

Figure 2: Surgical exposure showing 3-walled intra bony
defect between mandibular left lateral incisor and canine
teeth
The root surfaces were planed adequately and rough bony
margins were smoothened with bone files. An alloplastic bone
graft material (bioactive glass) was placed in the defect
(Figure 3). The mucoperiosteal flap was secured with 3-0
silk sutures.
Postsurgical instructions were given along with a course of
nonsteroidal anti-inflammatory drugs for three days. The
sutures were removed one week following the procedure. The
post-operative period was uneventful. The patient was
reviewed six months post operatively. Stable periodontal
tissue was noticed with a 2mm probing depth. Six months post
operative intraoral periapical radiograph revealed
appreciable bone fill in the interproximal area between
mandibular left lateral incisor and canine
(Figure 4).

Figure 3: Alloplastic bone graft material placed in the
defect

Figure 4:
Six months post operative radiograph showing bone fill seen
till the middle third of the root
Discussion
Loss of alveolar bone is one of the characteristic signs of
destructive periodontal disease and is generally considered
to represent the anatomical sequel to the apical spread of
periodontitis. One of the biggest challenges remaining in
dentistry is to predictably regenerate the alveolar bone
destroyed by periodontitis. Clinicians have long tried with
varying degrees of success to induce osseous regeneration,
cementum formation & fibrous attachment to achieve new
attachment. With recent advances there has been a shift in
the concepts of resective osseous surgeries to regenerative
surgeries which has changed the aim for treatment of
periodontal procedures from only repair to gaining new
attachment of the defects. Disadvantages of autogenous
grafts like requirement of additional surgical procedure,
antigenic and disease transmission potential of allografts
and xenografts,5 prompted the use of alloplastic
graft material in the present study.
Bioactive ceramics have been used clinically to repair bone
defects owing to their biological affinity to living bone;
i.e. the capability of direct bonding to living bone, their
so-called Bioactivity.6 The radiographic evidence
in the case presented here shows marked bone fill which is
consistent with a review of the literature that has shown
synthetic graft materials to date have functioned primarily
as biocompatible defect fillers.7
Conclusion:
Osseous regenerative procedure presented here, using
bioactive glass showed improved healing outcomes when
probing depth reduction, osseous defect fill, and gain in
clinical attachment are used as clinical parameters. A six
month post surgical follow up revealed a structurally and
functionally stable periodontal architecture both clinically
as well as radiographically. Case selection is particularly
important to the use and success of bone replacement
grafts. Higher success rates in regenerative osseous
techniques have been seen in treatment of 3 walled bone
defects. Also the patient must be highly motivated and
demonstrate the ability to effectively remove bacterial
plaque from every surface of every tooth on a daily basis.
References:
-
1.Schwartz Z,
Goultschin J, Dean DD & Boyan BD. Mechanism of
alveolar bone destruction in periodontitis.
Periodontol 2000, Vol. 14, 1997, 158-172.
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2.Schallhorn RG. Present status of osseous grafting
procedures.J Periodontol 1977: 48: 570-576.
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3.Reynolds M,
Aichelmann-Reidy W, Branch-Mays G. The efficacy of bone
replacement grafts in the treatment of periodontal
osseous defects. A systematic review. Ann Periodontol
2003;1:227–65.
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4.Dragoo MR,
Sullivan HC. A clinical and histological evaluation of
autogenous iliac bone grafts in humans. I. Wound healing
2 to 8 months. J Periodontol 1973;44(10):599–613.
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5.Sonis T, Williams L, Jeffcoat M. Healing of
spontaneous periodontal defects in dogs treated with
xenograft demineralized bone. J Periodontol 1985; 56:
470.
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6.Ohtsuki C, Kamitakahara M, Miyazaki T. Bioactive
ceramicbased materials with designed reactivity for bone
tissue regeneration. J R Soc Interface. 2009;6 Suppl
3:S349-60.
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7.Garrett S.
Periodontal regeneration around natural teeth. Ann
Periodontol 1996:1:638-639.
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