|Year : 2021 | Volume
| Issue : 6 | Page : 933-937
Bone regenerative biomaterials in periapical surgery: A systemic review and meta-analysis
Ananad Sumangali1, Amruta C Naik2, Nimisha Mohan3, Nivedita Gautam4, Surbhi Abrol5, Mohammed Mustafa6, Heena Tiwari7
1 Department of Endodontics, Sebha Dental College, University of Sebha, Sebha, Libya
2 MDS, Consultant Pediatric and Preventive Dentist, Pune, Maharashtra, India
3 Associate Professor, Department of Conservative Dentistry and Endodontics, Government Dental College, Kannur, Kerala, Pune, India
4 BDS, MPH, Claremont Graduate University, School of Community and Global Health, Claremont, CA, USA
5 Department of BDS, MDS, AS DMD Candidate, Boston University, USA
6 Department of Conservative Dental Sciences, College of Dentistry, Prince Sattam Bin Abdulaziz University, Alkharj, Saudi Arabia
7 BDS, PGDHHM, MPH, Final Year Student, Parul Univeristy, Limda, Waghodia, Vadodara, Gujrat, India
|Date of Submission||13-May-2021|
|Date of Decision||18-May-2021|
|Date of Acceptance||21-May-2021|
|Date of Web Publication||10-Nov-2021|
Parul University, Limda, Waghodia, Vadodara, Gujarat
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: Successful treatment in the endodontics and periodontics depends on the periapical status. Hence, in the present meta-analysis, we evaluate the various bone regenerative materials in the periapical surgeries. Materials and Methods: Online data were collected from the search engines of EBSCO, PubMed, Google Scholar, and Scopus. The searched terms were bone regenerative, bone grafts, bio materials, periapical surgery, and endodontic surgery. Based on the PRISMA guidelines, the meta-analysis was performed. The studies for the past 10 years were considered that included at least 10 patients. The translatable articles were included that had the human studies that were clinical studies and/or trials and also had the bone regenerative materials used in the procedure. Results: A total of 475 articles were selected, of which 30 were selected based on the criteria. Of these, after the removal of the 21 duplicate articles, 9 articles were finalized. The meta-analysis showed that when the bone graft materials are used along with the barriers for the regeneration, there were observed higher success rates. Conclusions: The bone regenerative materials can be used for the successful outcome for the periapical surgeries. The guided tissue regeneration along with the bone regenerative materials may aid in the good prognosis of the endodontic and periodontal cases.
Keywords: Biomaterials, bone grafts, bone regenerative, endodontic surgery, periapical surgery
|How to cite this article:|
Sumangali A, Naik AC, Mohan N, Gautam N, Abrol S, Mustafa M, Tiwari H. Bone regenerative biomaterials in periapical surgery: A systemic review and meta-analysis. J Pharm Bioall Sci 2021;13, Suppl S2:933-7
|How to cite this URL:|
Sumangali A, Naik AC, Mohan N, Gautam N, Abrol S, Mustafa M, Tiwari H. Bone regenerative biomaterials in periapical surgery: A systemic review and meta-analysis. J Pharm Bioall Sci [serial online] 2021 [cited 2022 Aug 10];13, Suppl S2:933-7. Available from: https://www.jpbsonline.org/text.asp?2021/13/6/933/330119
| Introduction|| |
One of the many modalities to save the decayed tooth is by endodontic treatment that relies on the removal of all the infectious agents from the periapical zone. However, the total elimination of the pathology from the periapical tissues is not easy. In the previous studies, the average time for the total elimination and the healing is seen to be an average of 5 years. Even after thorough debridement, the pathogens may persist. Hence in severe and refractory cases, the periapical surgery is suggested to save the tooth as a last resort before the extraction., The success of this periapical surgery includes the regeneration of the periodontium., In the regeneration for the periodontium, the bone grafts, regenerative materials, barrier membranes are used., There are studies related to the healing in the endodontic and periodontal surgeries by using the guided tissue regeneration (GTR), bone grafts, etc. However, there is less uniformity in these studies. The design and the criteria of the materials used in these studies are highly variable.,,,,,,, For performing the periapical surgery, there are few indications set by the periodontic and endodontic societies. These criteria are to be met for performing the periapical surgeries. When following these criteria and by the application of the GTR along with the bone regenerative materials, there have been successful results obtained previously.,,,, However, in these studies, the prognosis is inconsistent in these studies. Hence in the present meta-analysis, we evaluate the various bone regenerative materials and the barriers that are used for the periapical surgeries. Along with these, the prognostic factors that may aid in the success of the treatment are assessed.
| Materials and Methods|| |
Online data were collected from the search engines of EBSCO, PubMed, Google Scholar, Scopus. The searched terms were bone regenerative, bone grafts, bio materials, periapical surgery, and endodontic surgery. Based on the PRISMA guidelines, the meta-analysis was performed. The studies for the past 10 years were considered that included at least 10 patients. The studies with the barrier membrane and/or the bone regenerative materials used in the procedure were included.
The following inclusion criteria were set
- Application of the GTR
- Application of the bone regenerative material
- Minimum number of the subjects = 10
- Languages are to be in English or any other translatable languages
- Human studies only
- Full text available.
The exclusion criterion was:
- Poor design
- Languages that required permission to translate
- Animal studies
- Only abstracts available without the full text.
Two reviewers were selected for the study. The entire text was evaluated after the title, and the abstracts were selected for the study. Any disputes were cleared by consensus. The most appropriate studies that fit in the inclusion and the exclusion criteria were considered for the study.
| Results|| |
A total of 475 articles were selected. In these articles, 445 were excluded after the titles or the abstract didn't fit the study criteria. Thirty studies fit in the selection criteria. Of these, after the removal of the 21 duplicate articles, nine articles were finalized. The flowchart showing the article selection is shown in [Figure 1].
The meta-analysis showed that when the bone graft materials are used along with the barriers for the regeneration, there were observed higher success rates. These nine articles were selected for the preparation of the extraction data, and meta-analysis was done.,,,,,,, The data contained the method of the surgery performed, the material used for the regeneration, the GTR, tooth, or the segment that was involved that was arranged in a tabular form.
Among these nine articles, one was a case report, the remaining were clinical trials.,,,,,,, The arrangement of these studies was done based on the level of the evidence on the rank established based on the strength of recommendation taxonomy principles. In these nine studies, five were with level 2,,,, and four had level one.,,, The demographics noted from these studies are depicted in [Table 1].
The studies were considered for the method of the surgery done, the type of the defect, the graft used, the material used, the subjects in the study and the success rate [Table 2].
We observed that five of the selected studies were dissimilar. The study of the remaining four was comparable. The five studies were without clear randomization protocol, there was no clear evaluation of the outcome, some studies were seen where the patients were not followed up, and also there were differences of the subjects between the case and the control groups. This made the statistical analysis difficult due to the heterogeneous nature of the previous studies included in the review.
| Discussion|| |
In the study of von Arx and Cochran, they proposed the membranes to be used for the various types of the lesions and defects. They set criteria to classify the lesion type that is based on the certain characteristics of the lesion-like area. They identified four types of the lesion. In the present study, we considered the periapical lesions based on these criteria.
In the present study, we observed that when the bone regenerative materials are used in the four-wall defects of the periapical surgeries, there was a nearly 100% success rate combining a synthetic bioactive resorbable hydroxylapatite than with only barriers. This was clearly evident by the clinical and radiographic observations. When the Bio-Oss® that is xenograft (bovine bone) was used with the GTR, the success was higher than when the two were not applied for the periapical surgery in the through and through lesions. When the resorbable barrier membrane and the Bio-Oss® were used, the clinical and the radiographic signs significantly improved in the through and through periapical lesions.
For the endoperiodontal cases, only 50% of the success was seen with the application of the polyglactin alone, but with the platelet-rich plasma (PRP), the success rate significantly improved. However, the control group was not seen in this study. By performing the periapical surgery, the access to the region of the periapical tissues is attained easily. Sometimes the bone has to be removed in these procedures. The surgery also helps in healing. However, the previous tissue is not formed, but a new tissue regenerates. The regeneration of the tissue at the site of the periapical surgery is dependent on the native cells at the apex.,,,, The epithelial cell migration in the wound area is the fastest. The GTR is based on the regeneration of the periodontium.,,,,,,,,, This method has been used in the implant surgeries, endodontics, periodontics for the regeneration. This procedure makes use of the barrier membranes that guide the cells for the periapical tissue regeneration.
On the other hand, the bone grafts help in the regeneration of the periapical bone. These may be of a variety of types like auto/allo/xenografts. They may be inductive or conductive.,, Usually, Ox bone is applied.,,,,,,,, Calcium phosphate silicate, β-tricalcium phosphate, or calcium sulfate,, are synthetic materials.
The barrier is required to give time and base for the repopulation of the periapical cells that are bone and Periodontal Ligament cells. In the early cases, the nonresorbable membranes were used. However, due to the requirement of the second surgery, these were replaced by the resorbable membranes.
There are studies that show that periapical surgery alone has a good prognosis in the four-wall defects. The application of the GTR in these cases has been criticized with increasing cost. In the study of Dominiak et al. they showed that in the four-wall defect, the maximum success was seen when the Bio-Oss® + PRP than in those where only periapical surgery is done. We also observed that the bone regenerative material when used along with the GTR the maximum success as seen in the through and through periapical defects.,, In the study of the Taschieri et al. they stated that when in combination with the endodontic surgery, the barrier membranes may be successfully used for the through and through periapical defects. In a similar study Pecora et al. stated that when the Ca2So4 is placed for these defects, they may act as a barrier and also sealing material. These barriers and the bioactive materials may aid in good prognosis, however, the studies done previously are inconclusive when compare with the control groups. One of the barriers is that the autogenous periosteal grafts may be used alternative to the routine barriers. The advantage of the above membrane is that it can promote the osteogenic cells that help in the bone formations in these lesions. The previous study done by Marín-Botero et al. stated that superior results were obtained when the autogenous periosteal grafts were applied, than the regular barrier that was absorbable in the cases with the apicomarginal defect. However, in their study, they also stated that the success of their study might be influenced by periodontal status of the patients, the size, and the lesion shape. Furthermore, the reports were based on small sample size that could be a limitation in their study.
For the other materials that may help in the bone regeneration is the PRP. This PRP has the immune-modulatory effect that will help in the bone regeneration., In the study of Dominiak et al. they observed that the bone regenerative materials when used with the PRP the success was above 90% which was higher when compared to the bone grafts alone. Similarly, for the apicomarginal lesions, the PRP aided for the regenerative process that was evident in the successful outcomes. These were evident on the clinical assessment and radiographs., In the four-wall defects, the bone regeneration was greater in the GTR + OsteoGen® group than when used alone. Similar observations for the Bio-Oss® + Bio-Gide® were registered for the through and through lesions, as shown in [Table 2].
These bone regenerative materials have aided in the correction of the defects that are generally a situation faced by the clinicians for these periapical surgeries.
From our study, it is evident that the Bio-Oss® combined with the barrier Bio-Gide® has shown superior outcome for the various defects. However, there has been a paucity of the research in the through-and-through defect.,,,,, In the four-wall lesions the combinations OsteoGen® + Gore-Tex® and Bio-Oss® + Bio-Gide®, show comparable results.
In the present study, the success was studied based on the clinical, histological, and radiographic evaluations. For the appreciation of the radiographic outcome, the average period suggested is 1 year. The follow-up for such long periods is seldom done in the previous studies. Furthermore, when the xenografts are used, the appearance of the radiograph has shown more opaque that may be misleading.,,, Furthermore, the interpretation of the radiograph is prone to bias as there is interobserver variability.
One study in the present analysis used the histological evaluation for the periapical status after the surgery. This is not often considered on the ethical grounds. However, it is the most reliable method.
Some authors have opined that the criteria put forward by von Arx and Kurt may help in calculating the success after the periapical surgery.
The following prognostic factors can be suggested from our study when the bone regenerative material and the barriers are used for the periapical surgery:
- The location of the tooth
- Amount of bone loss
- Type of the defect
- Periodontal status.
There were some limitations in our study. The included articles were highly heterogeneous. The sample size was small in almost all the included studies. Furthermore, the control groups were not uniform in few studies.
| Conclusions|| |
It can be concluded from our study that the combination of the bone regenerative biomaterials along with the barriers performs well in the periapical surgeries. Further, well-planned studies are suggested with larger samples.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ng YL, Mann V, Gulabivala K. Tooth survival following non-sur- gical root canal treatment: A systematic review of the literature. Int Endod J 2010;43:171-89.
Tsesis I, Rosen E, Tamse A, Taschieri S, Del Fabbro M. Effect of guided tissue regeneration on the outcome of surgical endodontic treatment: A systematic review and meta-analysis. J Endod 2011;37:1039-45.
Goyal B, Tewari S, Duhan J, Sehgal PK. Comparative evaluation of platelet-rich plasma and guided tissue regeneration membrane in the healing of apicomarginal defects: A clinical study. J Endod 2011;37:773-80.
Pantchev A, Nohlert E, Tegelberg A. Endodontic surgery with and without inserts of bioactive glass PerioGlas®
– A clinical and radiographic follow-up. J Oral Maxillofac Surg 2009;13:21-6.
von Arx T, AlSaeed M. The use of regenerative techniques in apical surgery: A literature review. Saudi Dent J 2011;23:113-27.
Carrillo C, Penarrocha M, Bagan JV, Vera F. Relationship between histological diagnosis and evolution of 70 periapical lesions at 12 months, treated by periapical surgery. J Oral Maxillofac Surg 2008;66:1606-9.
Penarrocha M, Marti E, Garcia B, Gay-Escoda C. Relationship of periapical lesion radiologic size, apical resection, and retrograde filling with the prognosis of periapical surgery. J Oral Maxillofac Surg 2007;65:1526-9.
Peñarrocha M, Carrillo C, Peñarrocha M, Peñarrocha D, von Arx T, Vera F. Symptoms before periapical surgery related to histologic diagnosis and postoperative healing at 12 months for 178 periapical lesions. J Oral Maxillofac Surg 2011;69:e31-7.
Bashutski JD, Wang HL. Periodontal and endodontic regeneration. J Endod 2009;35:321-8.
Kinaia BM, Chogle SM, Kinaia AM, Goodis HE. Regenerative therapy: A periodontal-endodontic perspective. Dent Clin North Am 2012;56:537-47.
Pecora G, De Leonardis D, Ibrahim N, Bovi M, Cornelini R. The use of calcium sulphate in the surgical treatment of a 'through and through' periradicular lesion. Int Endod J 2001;34:189-97.
Lin L, Chen MY, Ricucci D, Rosenberg PA. Guided tissue regeneration in periapical surgery. J Endod 2010;36:618-25.
Naylor J, Mines P, Anderson A, Kwon D. The use of guided tissue regeneration techniques among endodontists: A web-based survey. J Endod 2011;37:1495-8.
Dietrich T, Zunker P, Dietrich D, Bernimoulin JP. Periapical and periodontal healing after osseous grafting and guided tissue regeneration treatment of apicomarginal defects in periradicular surgery: Results after 12 months. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;95:474-82.
Taschieri S, Del Fabbro M, Testori T, Saita M, Weinstein R. Efficacy of guided tissue regeneration in the management of through- and-through lesions following surgical endodontics: A preliminary study. Int J Periodontics Restorative Dent 2008;28:265-71.
Dominiak M, Lysiak-Drwal K, Gedrange T, Zietek M, Gerber H. Efficacy of healing process of bone defects after apicectomy: Results after 6 and 12 months. J Physiol Pharmacol 2009;60 Suppl 8:51-5.
Tobon SI, Arismendi JA, Marin ML, Mesa AL, Valencia JA. Comparison between a conventional technique and two bone regeneration techniques in periradicular surgery. Int Endod J 2002;35:635-41.
von Arx T, Cochran DL. Rationale for the application of the GTR principle using a barrier membrane in endodontic surgery: A proposal of classification and literature review. Int J Periodontics Restorative Dent 2001;21:127-39.
Taschieri S, Corbella S, Tsesis I, Bortolin M, Del Fabbro M. Effect of guided tissue regeneration on the outcome of surgical endodontic treatment of through-and-through lesions: A retrospective study at 4-year follow-up. Oral Maxillofac Surg 2011;15:153-9.
Marín-Botero ML, Domínguez-Mejía JS, Arismendi-Echavarría JA, Mesa-Jaramillo AL, Flórez-Moreno GA, Tobón-Arroyave SI. Healing response of apicomarginal defects to two guided tissue regeneration techniques in periradicular surgery: A double-blind, randomized-clinical trial. Int Endod J 2006;39:368-77.
Taschieri S, Testori T, Azzola F, Del Fabbro M, Valentini P. Guided-tissue regeneration in endodontic surgery. Rev Stomatol Chir Maxillofac 2008;109:213-7.
Taschieri S, Del Fabbro M, Testori T, Weinstein R. Efficacy of xenogeneic bone grafting with guided tissue regeneration in the management of bone defects after surgical endodontics. J Oral Maxillofac Surg 2007;65:1121-7.
Velard F, Braux J, Amedee J, Laquerriere P. Inflammatory cells response to calcium phosphate biomaterial particles: An overview. Acta Biomater 2013;9:4956-63.
Martí Bowen E, Peñarrocha M. An update in periapical surgery. Med Oral Patol Oral Cir Bucal 2006;11:E503-9.
Peñarrocha Diago M, Ortega Sánchez B, García Mira B, Martí Bowen E, von Arx T, Gay Escoda C. Evaluation of healing criteria for success after periapical surgery. Med Oral Patol Oral Cir Bucal 2008;13:E143-7.
[Table 1], [Table 2]