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Azerbaycan Saytlari

 »  Home  »  Endodontic Articles 3  »  Guided bone regeneration (GBR) using membranes and calcium sulphate after apicectomy: a comparative histomorphometrical study
Guided bone regeneration (GBR) using membranes and calcium sulphate after apicectomy: a comparative histomorphometrical study
Discussion - References.

The process and modes of healing in the osseous defect were similar histologically in all groups at each period. The histological findings using a light microscope and a fluorescence microscope showed that bone regeneration occurred diffusely about 2 weeks after the surgery. At 8 weeks, the volume of new bone labelled by fluorescence dyes in the osseous defect was greater than that at 16 weeks. Namely, the activity of bone regeneration at 8 weeks was higher than that at 16 weeks. The osseous defects were closed by newly formed cortical bone in all specimens at 16 weeks, and it appeared that bone remodelling activity in the osseous defect at 16 weeks was close to normal.
Many studies have reported that e-PTFE membrane is an excellent material for GTR in periodontal treatment (Kon et al. 1991, Caffesse et al. 1994, Cortellini et al. 1996). Also, several studies have shown that GBR using e-PTFE membrane is an effective technique because of its high ability to create a secluded space (Dahlin et al. 1989, 1990, Nyman 1991, Pecora et al. 1995, Simion et al. 1996, Ito et al. 1998). Dahlin et al. (1990) was the first to report in endodontics that bone regeneration using e-PTFE membrane was predictably achieved in osseous defects. Pecora et al. (1995) reported in a clinical study that GTR principle using e-PTFE membrane could be applied effectively to the healing of large periapical lesions. Simion et al. (1996) and Ito et al. (1998) compared the bone regeneration histologically when resorbable and non-resorbable membranes were applied to osseous defects. They concluded that e-PTFE membrane was most effective for GBR. In the present study, the percentage of bone volume (BV/TV) using e-PTFE membrane was significantly higher, and the concavity of new cortical bone using e-PTFE membrane was smaller than that in controls. As such, the application of e-PTFE membrane to the osseous defect in conjunction with apicectomy was an effective technique to achieve bone regeneration.

collagen membrane; group D, calcium sulphate
Figure 5. Representative sections at 16 weeks. Group A, e-PTFE membrane; group B, PLGA membrane; group C, collagen membrane; group D, calcium sulphate; group E, controls ( 1, Villanueva's bone stain).

fibrous tissue; B, newly formed cortical bone
Figure 6. Representative section in group B at 16 weeks after the surgery. Asterisks, the trace of PLGA membrane; F, fibrous tissue; B, newly formed cortical bone ( 5, Villanueva's bone stain).

In periodontology, Caffesse et al. (1994) and Cortellini et al. (1996) reported that similar findings could be achieved in GTR procedures when PLGA membrane and e-PTFE membrane were applied. However, Simion et al. (1996) reported that PLGA membrane produced some bone regeneration when compared with controls, but to a lesser extent than e-PTFE membrane. In the present study, PLGA membrane was inferior to e-PTFE membrane and not superior to controls in bone regeneration. The fibrous tissue between the PLGA membrane and the new cortical bone was thick, so that the new cortical bone in the PLGA membrane group was remarkably concave compared with the other groups. Possibly, the PLGA membrane was less biocompatible than e-PTFE membrane, collagen membrane, and calcium sulphate.
Collagen is known to show different effects on tissue healing depending on its type, structure, condition of cross-linking and the type of chemical treatment it has undergone. Furthermore, in GTR, microfibrillar collagen membrane, purified from bovine corium collagen, did not effectively prevent apical migration of epithelium in humans (Tanner et al. 1988). However, Zahedi et al. (1998) reported that diphenylphosphorylazide (DPPA), crosslinked collagen membrane, had physico-chemical characteristics compatible with the requirements for GBR. The collagen membrane used in this study was made from atelocollagen that was type I collagen, purified from bovine dermis and solubilized with pepsin. Minabe et al. (1989) reported that the use of atelocollagen membrane in periodontal wounds suppressed the epithelial down-growth along the root surfaces, which rapidly reduced postoperative inflammatory reaction and foreign body giant cell reaction compared with controls. In the present study, however, atelocollagen membrane was not effective for bone regeneration after apicectomy compared with controls.
The resorbable membranes used in this study were not effective for bone regeneration compared with e-PTFE membrane, and not different from controls. Another resorbable membrane, polylactic acid (PLA) membrane, has been applied in GTR (Magnusson et al. 1990, Gottlow et al. 1994) and GBR (Uchin 1996, Maguire et al. 1998, Ito et al. 1998, Bohning et al. 1999). Uchin (1996) indicated that the GBR procedure using PLA membrane was an effective technique as an adjunct to endodontic surgery. However, Bohning et al. (1999) found no statistically significant difference in bone regeneration in rat calvaria, whether the GBR using PLA membrane was introduced or not. Maguire et al. (1998) reported that the use of PLA membrane did not show a significant positive effect on periradicular osseous healing in cats. Explanations for these findings include:

  1. the resorption period of the resorbable membranes might be too short for bone regeneration;
  2. the resorbable membranes might not have sufficient stiffness to prevent them from collapsing into the osseous defect; and
  3. resorption of membrane might adversely affect bone regeneration.

Calcium sulphate has been applied to osseous defects (Peltier 1961, Calhoun et al. 1965, Pecora et al. 1997a,b). This material is inexpensive, easy to apply, biocompatible, and completely resorbable. Membranes should be trimmed to cover at least 2–3 mm beyond the margins of the osseous defect and be totally submerged under the repositioned flap to minimize postoperative infection risk (Pecora et al. 1997b). This makes application of the membranes complicated. However the application of calcium sulphate is not difficult, because it is simply mixed and plugged into the osseous defect. Studies reported that the resorption of calcium sulphate and subsequent regeneration of bone occurred rapidly over a period of weeks or months (Peltier 1961, Pecora et al. 1997a, Kim et al. 1998a,b). Yamazaki et al. (1988) suggested that the resorption period of calcium sulphate might be related to its density. In the present study, calcium sulphate was resorbed at 4 weeks. This was similar to the previous report (Pecora et al. 1997a). Bone regeneration using calcium sulphate was similar to that using e-PTFE membrane and superior to controls in the present study. Although many studies reported that the application of calcium sulphate achieved good bone regeneration, its true mechanism is unclear (Peltier 1961, Calhoun et al. 1965, Pecora et al. 1997a). Yamazaki et al. (1988) reported that calcium sulphate did not induce bone formation in the femoral muscle pouch in mice at 6 weeks after implantation of calcium sulphate. Possibly, the calcium sulphate may not be osteoinductive but osteoconductive.
In the present study, controls were inferior to e-PTFE membrane and calcium sulphate with respect to the bone volume. Without bone regeneration after apicectomy, the prognosis of the tooth might be compromised because of insufficient resistance against occlusal forces and possible periodontitis in the long term. Also, if the contours of the alveolar bone are concave when the teeth are extracted, prosthodontic procedures or treatment with dental implants might be more difficult to perform. Therefore, it is important to regenerate bone tissue into the osseous defect in conjunction with apicectomy to accomplish predictable treatments.


Andreana S (1998) A combined approach for treatment of developmental groove associated periodontal defect. A case report. Journal of Periodontology 69 , 601-7.
Andreasen JO, Rud J (1972) Modes of healing histologically after endodontic surgery in 70 cases. International Journal of Oral Surgery 1 , 148-60.
Bohning BP, Davenport WD, Jeansonne BG (1999) The effect of guided tissue regeneration on the healing of osseous defects in rat calvaria. Journal of Endodontics 25 , 81-4.
Caffesse RG, Nasjleti CE, Morrison EC, Sanchez R (1994) Guided tissue regeneration: comparison of bioabsorbable and nonbioabsorbable membranes. histologic and histometric study in dogs. Journal of Periodontology 65 , 583-91.
Calhoun NR, Greene GW, Blackledge GT (1965) Plaster: a bone substitute in the mandible of dogs. Journal of Dental Research 44 , 940-6.
Cortellini P, Prato GP, Tonetti MS (1996) Periodontal regeneration of human intrabony defects with bioresorbable membranes. A controlled clinical trial. Journal of Periodontology 67, 217-23.
Dahlin C, Sennerby L, Lekholm U, Linde A, Nyman S (1989) Generation of new bone around titanium implants using a membrane technique: an experimental study in rabbits. International Journal of Oral and Maxillofacial Implants 4, 19-25.
Dahlin C, Gottlow J, Linde A, Nyman S (1990) Healing of maxillary and mandibular bone defects using a membrane technique. Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery 24, 13-9.
Gottlow J, Laurell L, Lundgren D et al. (1994) Periodontal tissue response to a new bioresorbable guided tissue regeneration device: a longitudinal study in monkeys. International Journal of Periodontics and Restorative Dentistry 14, 436-49.
Ito K, Nanba K, Murai S (1998) Effects of bioabsorbable and non-resorbable barrier membranes on bone augmentation in rabbit calvaria. Journal of Periodontology 69, 1229-37.
Kellert M, Chalfin H, Solomon C (1994) Guided tissue regeneration: an adjunct to endodontic surgery. Journal of the American Dental Association 125, 1229-33.
Kim CK, Kim HY, Chai JK et al. (1998a) Effect of a calcium sulfate implant with calcium sulfate barrier on periodontal healing in 3-wall intrabony defects in dogs. Journal of Periodontology 69, 982-8.
Kim CK, Chai JK, Cho KS, Choi SH (1998b) Effect of calcium sulphate on the healing of periodontal intrabony defects. International Dental Journal 48 (Suppl. 1), 330-7.
Kon S, Ruben MP, Bloom AA, Mardam-Bey W, Boffa J (1991) Regeneration of periodontal ligament using resorbable and nonresorbable membranes: clinical, histological, and histometric study in dogs. International Journal of Periodontics and Restorative Dentistry 11, 58-71.
Magnusson I, Stenberg WV, Batich C, Egelberg J (1990) Connective tissue repair in circumferential periodontal defects in dogs following use of a biodegradable membrane. Journal of Clinical Periodontology 17, 243-8.
Maguire H, Torabinejad M, McKendry D, McMillan P, Simon JH (1998) Effects of resorbable membrane placement and human osteogenic protein-1 on hard tissue healing after periradicular surgery in cats. Journal of Endodontics 24, 720-5.
Minabe M, Kodama T, Hori T, Watanabe Y (1989) Effects of atelocollagen on the wound healing reaction following palatal gingivectomy in rats. Journal of Periodontal Research 24, 178-85.
Nyman S, Lindhe J, Karring T, Rylander H (1982) New attachment following surgical treatment of human periodontal disease. Journal of Clinical Periodontology 9, 290-6.
Nyman S (1991) Bone regeneration using the principle of guided tissue regeneration. Journal of Clinical Periodontology 18, 494-8.
Pecora G, Kim S, Celletti R, Davarpanah M (1995) The guided tissue regeneration principle in endodontic surgery: one-year postoperative results of large periapical lesions. International Endodontic Journal 28, 41-6.
Pecora G, Andreana S, Margarone JE III, Covani U, Sottosanti JS (1997a) Bone regeneration with a calcium sulfate barrier. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics 84, 424-9.
Pecora G, Beak SH, Rethnam S, Kim S (1997b) Barrier membrane techniques in endodontic microsurgery. Dental Clinics of North America 41, 585-602.
Peltier LF (1961) The use of plaster of Paris to fill defects in bone. Clinical Orthopaedics and Related Research 21, 1-29.
Radentz WH, Collings CK (1965) The implantation of plaster of Paris in the alveolar process of the dog. Journal of Periodontology 36, 357-64.
Simion M, Scarano A, Gionso L, Piattelli A (1996) Guided bone regeneration using resorbable and nonresorbable membranes: a comparative histologic study in humans. International Journal of Oral and Maxillofacial Implants 11, 735-42.
Tanner MG, Solt CW, Vuddhakanok S (1988) An evaluation of new attachment formation using a microfibrillar collagen barrier. Journal of Periodontology 59, 524-30.
Uchin RA (1996) Use of a bioresorbable guided tissue membrane as an adjunct to bony regeneration in cases requiring endodontic surgical intervention. Journal of Endodontics 22, 94-6.
Yamazaki Y, Oida S, Akimoto Y, Shioda S (1988) Response of the mouse femoral muscle to an implant of a composite of bone morphogenetic protein and plaster of Paris. Clinical Orthopaedics and Related Research 234, 240-9.
Zahedi S, Legrand R, Brunel G et al. (1998) Evaluation of a diphenylphosphorylazide-crosslinked collagen membrane for guided bone regeneration in mandibular defects in rats. Journal of Periodontology 69, 1238-46.