To evaluate and compare the effectiveness of demineralized freeze dried block graft and freeze dried block graft with chorion membrane as barrier membrane clinically and radiographically for the treatment of residual deep intra bony defects.

2. Comparative study of DFDBA and FDBA block grafts
in combination with chorion membrane for the
treatment of periodontal intra-bony defects at 12
months post surgery
Shaila Kothiwale . Rishi Bhimani . Murtaza Kaderi . Jyoti Ajbani
Dr. Beena Vijayan Parvathy
Post graduate
Department of Periodontics
11 FEB 2019

3. INTRODUCTION
• Mcguire and Nunn 1996
• Cortellini and Tonetti 2004
• Sources of osseous substitute grafts include autogenous, allogeneic, alloplastic, and
xenogeneic materials.
• The periodontally compromised deep intra-bony defects do not provide a natural retention to
contain the particulated grafting material. Consequently, block grafts can be recommended
in such clinical scenarios. Therefore, such graft must possess strength and rigidity to allow
its fixation in the recipient site and have stability to withstand muscular forces.

4. • Though autogenous bone grafts have always been the gold standard material, this
additional surgical procedure may have increased postoperative morbidity and
postoperative complications. Autogenous block graft harvesting may result in upto
43% of some paresthesia (Nissan et al. 2011)
• The other possible alternative to the block autograft can be block allografts. The
studies have also demonstrated the combination of guided tissue regeneration with
osseous grafts have resulted in enhanced periodontal regeneration.

5. AIM
To evaluate and compare the effectiveness of demineralized freeze dried block graft and
freeze dried block graft with chorion membrane as barrier membrane clinically and
radiographically for the treatment of residual deep intra bony defects.

6. Materials and Methods
Study design
• 9 systemically healthy patients aged between 35 and 55 years diagnosed with severe chronic
periodontitis with radiographic evidence of angular bone defects were selected for this study.
• The study was conducted from January 2016 to March 2017.
• Among 9 patients, two sites were selected in posterior area from each patient.
• The sites were randomly divided into group 1 (FDBA/chorion membrane) and group 2
(DFDBA/chorion membrane) by flip coin method.

7. Inclusion Criteria
1. PPD > 6 mm with radiographic evidence of osseous defect either in maxillary or mandibular
molar tooth.
2. No systemic antibiotics prescribed in past 6 months.
3. No surgical treatment of the site within one year before initiation of the study.
4. Presence of mobility from grade I to II.
5. No systemic disease.

8. Exclusion Criteria
1. Pregnant women and lactating mothers
2. Tobacco smokers
3. History of taking drugs which might affect periodontal healing.
4. Uncooperative patients.

9. Clinical and radiographic measurements
The following clinical parameters were recorded at the baseline and at 12 months post
operatively:
• Plaque Index and Gingival Index
• Periodontal pocket depth (PD)
• Clinical attachment level (CAL)
• All measurements were taken by the same examiner using graduated William’s
probe.

10. • Radiographs were taken by the standardized paralleling technique.
• Pre-operative radiographs were obtained at baseline, 6 months and 12 months
postoperatively.
• The area of the defect was calculated using the RVG software X-ray.
• The radiographs were statistically assessed at baseline and 12 months only.
Radiographic Measurements

11. • Eickholz et al 2004 identified the following landmarks, which were used in the current study
to calculate the area of defect on the radiographs.
1. Cemento-enamel junction (CEJ): If the CEJ was destroyed by restorative treatment, the margin of
the restoration was taken as a landmark.
2. Bony defect was defined as the most coronal point where the periodontal ligament space showed a
continuous width.
3. Alveolar crest (AC) was defined as the crossing of the silhouette of the AC with the root surface.

12. Procedure
• The surgical treatment was performed 6 weeks after phase I therapy.
• Following phase 1 therapy, surgical treatment was attempted at the defect sites. A
Kirkland/conventional flap was designed.
• After anesthetizing the surgical site, horizontal incisions were taken, and the flap was
reflected till the base of the intra-bony alveolar defect sites following which the defects were
thoroughly debrided for the inflamed granulation tissue followed by root planning and
irrigation.
• After completion of debridement, the length, width and depth of the defects were measured
with the help of a sterile divider. These measurements were used to contour the block
allografts of appropriate sizes using micro motor diamond bur.

13. • Perforations were drilled into recipient bone surgical site, to induce the bleeding. The graft
was placed into the defect with proper adaptation to the defect site.
• The prepared graft was rinsed with sterile saline solution and stabilized into defect site. A
customized template was prepared with a tin foil for the desired length and width to adapt
over the block graft at the defect site extending 2–3 mm facially and lingually and 2 mm
mesio-distally.
• This tin foil was used to contour the chorion membrane which was used as a barrier
membrane to stabilize the bone graft. Chorion membrane of appropriate sizes was
contoured to cover the defect completely.

14. • The thickness of the Chorion membrane did not allow itself to shrivel and got adapted firmly
over the defect area. Care was taken not to expose the membrane before suturing.
• The periodontal flaps were adapted on the surgical site and sutured without any exposure of the
chorion membrane. Periodontal pack was placed at the surgical site to assure the comfort to the
patient

15. d) Flaps sutured
a) Flap reflection and assessment
of the bone defect.
b) Placement of Block graft in the
intra-bony defect.
c) Chorion
membrane placement covering the
bone graft.

16. Maintenance Program
• All the patients received the antibiotics [Amoxicillin (500 mg) and Metronidazole (400 mg)]
for 5 days and analgesics for 3 days.
• The patients were instructed for good maintenance of plaque supported with Chlorhexidine
mouthwash 0.12% for 4 weeks.
• Recall appointment was scheduled after 7 days for suture removal.
• Patients were placed on maintenance therapy every month to evaluate the oral hygiene
maintenance.

17. Statistical analysis
• Inter group comparison for clinical and radiographic parameters were calculated using
Mann–Whitney U test.
• The intra group comparison was done using Wilcoxon signed rank test.

18. Results
• 9 recruited patients with 18 sites as split mouth received the DFDBA and FDBA with
chorion membrane for treatment of deep intra bony defects and completed 12 months
observation period.
• Clinical parameters in the present study, plaque and gingival index which presented the
oral hygiene status showed significant reduction from base line to 12 months on intra
group comparison.
• The periodontal pockets which qualified for the regenerative periodontal treatment had
baseline mean in group 1 and group 2 showed reduction post treatment.
• The treatment resulted with the clinical attachment gain of 4.0922 ± 0.63 and 4.6278 ±
0.45 in group 1 and group 2.

19. At 12 months, post
treatment indicates
significant pocket
reduction and gain
in clinical
attachment in both
the groups (Table1).
Both the groups showed
significant reduction in
the defect depth at 12
months (Table 2).

20. However there was no
statistical significance
observed on inter group
comparison with
clinical parameters
(Table 4).
The intergroup
comparison among
both the groups for
bone fill was
statistically
insignificant (Table 3).

21. • The mobility of both groups significantly reduced (from grade I to grade II) grade 0 to
grade I.
• The mean of radiographic assessment bone defect in group 1 and group 2 at baseline were
7.3333 ± 0.66 and 7.2222 ± 1.02 and the mean bone fill of 2.5556 ± 0.41 and 2.9444 ±
0.58 respectively at 12 months.

22. Discussion
• There are various studies which have compared DFDBA and FDBA particles in furcation
involvement and intra-bony defect with and without GTR membranes.
• Clinical parameters showed reduction in Plaque Index from baseline for group 1 and 2 to post
treatment indicated good plaque maintenance.
• The pocket depth reduced with gain in the clinical attachment level in both the groups with no
statistical differences.
• The clinical gain in attachment was 3.96 ± 1.15 (FDBA) and 2.66 ± 0.33 (DFDBA) (Table 1).
There was no statistical significance on intergroup comparison (Table 4). Similar results were
reported by Rummelhart et al 1989 where DFDBA and FDBA particulate block grafts were
used.

23. • In the present study both the groups showed increase in bone density in radiograph (Table 2)
indicating formation of vital bone. Though radiovisiography revealed increase in the bone
density in both the groups.
• Group 1 showed statistical increase in bone density with FDBA.
• The FDBA and DFDBA block grafts received from tissue bank were cortico-cancellous. The
percentage of cortical or cancellous components in each block graft might have differed in
each block graft. This variation among cortico-cancellous component of block grafts might
have resulted in increased density in group 1.
• The separate healing patterns occurring in cancellous and cortical bone have earlier been
studied by histology and micro angiography Kenzora et al 1978.

24. Cortical bone first undergoes a stage of Resorption
Creating cavities in the dense bone
Wide-spread osteogenesis
Cancellous bone heals primarily by osteogenesis
Bone resorption
Weeks after the initiation of the healing phase
Old, dead cancellous trabeculae are partly surrounded by newly developed vital bone
• This appears as an increased X-ray density.
•The consecutive resorption process re-establishes the bone density found before surgery.
•The mobility of the selected teeth for both groups was between grade I and grade II at base line
reduced to physiological mobility and grade I respectively.

27. • The vascularisation of the graft is essential for healing and bone modeling. Early vascularization
means early remodeling. The vascularisation starts 5 days post- grafting. At 20 days the grafts
may be fully vascularised Albrektsson 1980.
• In the present study perforations were created at recipient surgical site to aid in vascularization
at the site. This may aid in proliferation of growth factors and platelets, which are essential in
wound healing Se´rgio et al. 2000.
• The radiovisiography of the present study revealed increase in the bone density in both the
groups, with statistical significant in group 1 (FDBA + Chorion membrane) (Table 2)
• The bone fill in the defect area indicates placement of bone grafts results in partial or complete
resolution of the intra-bony defect. However, the nature of the resolution of the defect whether
the graft acted as a scaffold or replaced for the growth of the bone cannot be inferred from the
radiographic observations.

28. • Piattelli et al 1996 demonstrated histologically observations between these two allografts.
• The DFDBA may serve as a scaffold for bone formation in an osteoconductive fashion.
• The mechanisms for bone formation induced by DFDBA could be:
(a) the particles undergo a biochemical change that brings about the remineralisation of the
particles;
(b) the demineralized particles are colonized by mononuclear osteoclasts from the
neighboring bone that are able to attract osteoblasts on their surface, thus allowing
successive bone layering.
• DFDBA particles located far from the host bone tended to be surrounded by a scarcely
cellular connective tissue, composed mainly of collagen fibers.
• In the DFDBA the osteocytic lacunae tended, for the most part, to remain empty.

29. • In the FDBA, all the osteocytic lacunae were filled by osteocytes and in some areas Haversian
systems with a capillary at the center were found. In the FDBA particles many particles were
completely surrounded by newly formed bone.
• Even the particles that were farthest from the host bone were lined by osteoblasts actively
secreting osteoid and newly formed bone. They pointed the results stating more
osteoconductive effect of FDBA. Similarly in this study also, sites with FDBA has shown
better bone fill and significant increase in bone density.
• In the present study chorion membrane used as a GTR played a dual role in stabilizing the
block grafts along at the surgical site and provided additional advantage of anti-inflammatory,
adhesion, growth factors and vascularisation properties Koob et al. 2013; Kothiwale 2014.
• The chorion membrane which is thicker than amnion provided stability and support to the
graft. Hence, the combination of Block grafts with the chorion membrane aided in the
statistically significant results in both the groups of the study.

30. Conclusion
• The application of FDBA and DFDBA block grafts in conjunction with chorion
membrane resulted in significant improvement in clinical and radiological parameters.
• With increasing loss of height, in wide angular defects, where the placement of
particles may be hard, combination approach with block allograft graft and chorion
membrane may be beneficial to achieve predictable periodontal regeneration.

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33. Thank you