Apr 6, 2012 - K. S. Hassan, A. S. Alagl, A. Abdel-Hady: Torus mandibularis bone ... The use of mandibular tori as autogenous bone graft combined with PRP.
Int. J. Oral Maxillofac. Surg. 2012; 41: 1519–1526 doi:10.1016/j.ijom.2012.02.009, available online at http://www.sciencedirect.com
Clinical Paper Oral Surgery
Torus mandibularis bone chips combined with platelet rich plasma gel for treatment of intrabony osseous defects: clinical and radiographic evaluation
K. S. Hassan1,2, A. S. Alagl3, A. Abdel-Hady4,5 1
Department of Preventive Dental Sciences, Division of Periodontics, College of Dentistry, University of Dammam, Saudi Arabia; 2Oral Medicine and Periodontology, Faculty of Dental Medicine, Al-Azhar University, Assiut Branch, Egypt; 3Department of Preventive Dental Sciences, College of Dentistry, University of Dammam, Saudi Arabia; 4Oral & Maxillofacial Surgery, College of Dentistry, University of Dammam, Saudi Arabia; 5Oral & Maxillofacial Surgery, Tanta University, Egypt
K. S. Hassan, A. S. Alagl, A. Abdel-Hady: Torus mandibularis bone chips combined with platelet rich plasma gel for treatment of intrabony osseous defects: clinical and radiographic evaluation. Int. J. Oral Maxillofac. Surg. 2012; 41: 1519–1526. Published by Elsevier Ltd on behalf of International Association of Oral and Maxillofacial Surgeons. Abstract. The use of platelet rich plasma (PRP) gel in combination with torus mandibularis offers a potentially useful treatment for periodontal osseous defects. Whether this combination enhances the outcome of periodontal regenerative therapy is not known. This study compared the effectiveness of torus mandibularis bone chips alone and when combined with autogenous PRP gel in treating periodontal osseous defects. 24 sites from 12 patients were selected using a split mouth design and determined by a double-blind, randomized, controlled clinical trial. Both sites received a full-thickness mucoperiosteal flap; one intrabony defect was filled with torus mandibularis bone chips alone and the other with torus mandibularis bone chips mixed with PRP gel. There was a 57% gain in the clinical attachment level and 60% reduction in the probing depth for torus mandibularis alone compared to 72% and 68% for sites treated with torus mandibularis and PRP gel (p 0.01). There was a statistically significant difference in the bone dentistry and the marginal bone loss at sites with PRP gel compared to those without gel (p 0.01). The use of mandibular tori as autogenous bone graft combined with PRP gel showed a significant improvement in the clinical outcome of periodontal therapy than mandibular tori alone.
Periodontal therapy is directed towards controlling the infection and regenerating the lost supporting structures. Periodontal 0901-5027/01201519 + 08 $36.00/0
regeneration refers to the restoration of supporting tissues of the teeth such as bone, cementum, and periodontal
Keywords: torus mandibularis; platelet rich plasma; intrabony osseous defects. Accepted for publication 15 February 2012 Available online 6 April 2012
ligament to their original healthy levels before periodontal tissue distraction has occurred. Over the last decades different
Published by Elsevier Ltd on behalf of International Association of Oral and Maxillofacial Surgeons.
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modalities of regenerative treatment have been developed and applied clinically. The positive effects of bone grafts and bone substitutes on the outcome of periodontal regenerative procedures are well documented. Historically, autografts were the first bone replacement grafts to be reported for periodontal applications. Allogenic freeze-dried bone was introduced to periodontics in the early 1970s, while demineralized allogenic freeze-dried bone gained wider application in the late 1980s. The introduction of xenografts and alloplasts for periodontal use occurred at the same time.1 Autogenous bone grafts are considered the gold standard graft material for reconstruction procedures; they are nonimmunogenic and contain osteoblasts and osteoprogenitor stem cells, which are capable of proliferating. These grafts are osteoinductive.2 The evidence that freeze-drying markedly reduces the antigenicity and other health risks associated with fresh frozen bone, as well as the favourable results obtained in field trials with freezedried bone allografts, have led to the extensive use of freeze-dried bone allografts in the treatment of periodontal osseous defects.3 The morbidity and limited availability associated with autografts, along with the potential for disease transmission, immunogenic response, and variable quality associated with allografts, have led to a variety of alternative materials. Bone exostoses and tori are localized peripheral overgrowths of bone that arise from the cortical plate and sometimes from the spongy layer4 due to some unknown cause. Although the aetiology is unknown, a hereditary basis is suspected. These developmental anomalies are not pathologically significant, and frequently develop in skeletal jaw. In this respect, different types of exotoses have been described; torus palatinus and torus mandibularis are two of the most common intraoral exostoses. The other types of exostoses such as buccal or palatal exostoses are less commonly encountered.5 Torus mandibularis which has reportedly been usually bilaterally is located in the lingual surfaces of the cusped/premolar area of the mandible and superior to the mylohyoid ridge.6,7 The lingual tori are unnecessary bony extensions, which may limit tongue space and create phonetic difficulties. Therefore, the tori may require surgical removal for prosthetic reasons. Removal of these exostoses can also assist with flap adaptation during periodontal surgery. A different approach to periodontal regeneration is the use of polypeptide growth factors (PGFs). These biologic
mediators have the ability to regulate cell proliferation, chemotaxis, and differentiation.8 Among the known PGFs, plateletderived growth factor (PDGF) and TGF-b have been studied the most extensively. PDGF has the primary effect of a mitogen, initiating cell division.9 Recombinant human PDGFBB, in combination with recombinant insulin-like growth factor-1, has been shown to exert a favourable effect on periodontal regeneration, as measured by the gain in clinical attachment level and osseous defect fill in humans.10 Upon activation, TGF-b facilitates wound healing under inflammatory conditions.11 PGFs, such as PDGF and TGF-b, are known to be abundant in the a-granules of platelets.12 The use of platelet-rich plasma (PRP) is a convenient and economical approach to obtain autologous PDGF and TGF-b. It involves the sequestration and concentration of platelets in plasma with subsequent application of this preparation to woundhealing sites. It has been shown that the application of PRP to the wound-healing site increases the concentration of platelets (and theoretically of PDGF and TGF-b) by up to 338%.13 The use of PRP and torus mandibularis in combination offers a potentially useful modality for treating periodontal osseous defects. It is unknown whether a combination of these materials would enhance the outcome of periodontal regenerative therapy. This study was carried out to compare the effectiveness of using the torus mandibularis bone chips alone and when combined with autogenous PRP gel in treating intrabony defects in patients with chronic periodontitis by analyzing the clinical and radiographic parameters. Materials and methods
12 patients (7 males and 5 females with an average age of 41.4 2.61 years) with chronic periodontitis were selected to participate in this randomized split mouth design study. The present clinical study was designed as a controlled clinical trial with a parallel design. Patients were selected from the outpatient clinic at University of Dammam, College of Dentistry, Kingdom of Saudi Arabia. Patients selected for this study were free from any systemic diseases, non-smokers, not pregnant (female cases), had a good level of oral hygiene, and had infrabony 2 osseous walls defect with a probing pocket depth (PPD) 6 mm and clinical attachment level (CAL) of 5 mm. 24 sites were selected by using a split mouth design for each patient determined randomly through a biased coin randomization. For each
patient; one site (group I) received a full-thickness mucoperiosteal flap and filling the infrabony defect with torus mandibularis bone graft alone. The other site (group II) received a full-thickness flap and filling with torus mandibularis bone graft mixed with PRP gel. Each patient was prepared for surgery with an initial phase of therapy including oral hygiene instructions and scaling and root planning. Approximately 4 weeks after initial therapy, patients were re-evaluated to assess clinical parameters and plaque control. All subjects had to achieve good oral hygiene (
