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p. N. Galgut', I. M.

Walte',
A 4-year controlled clinical study J. D. Brookshaw^ and
C. P. Kingston^

into the use of a ceramic 'University College and Middlesex School of


Dentistry. Mortimer Market. London WC1.
UK: "FacuHy of Dentistry. National University
of Singapore, Lower Kent Ridge Road

hydroxylapatite implant material Singapore 0511; ^(formerly) Sterling Winthrop


R & D, Onslow Street, Guiidford. Surrey GU1
4YS, UK

for the treatment of periodontal


bone defects
Galgu! PS. IVaiie IM. Brookshaw JD and King.stoii CP: A 4-vcar controlled
clinical sltidy in!<i the use ol a ceramic hydroxylapatile impltiM material tor the
treatment of periodontai hone defect.^. J Clin Periodontol 1992: 19; 570-5^7.

.-ib.stracL 10 patients with chronic adult periodontitis who had > I tooth with
infra-bony pockets were treated at the test delects hy periodontal Hap pro-
cedures with implantation of hydroxylapatite particles: the control defects were
treated by the same surgical procedures but without the implant, .\ total of 58
test defects and 59 control defects were treated. Each defect had measurements
carried out at given sites on the involved tooth surfaces, the sites being con-
sidered for subsequent tabulation purpo.ses under the category of shallow ( < 3
mm) moderate (3-6 mm) and deep ( > 6 mm) initial pocket depths. There were
146 and 152 shallow sites. 216 and 241 moderate sites and 140 and 133 deep
sites, at test and control sites, respectively. Measurements of recession, probing
pocket depths and probing attachment levels were made at 6 months and 1. 2. 3
and 4 years. .At all sites over the period of the study, for the moderate and deep
initial pockets there was a significant reduction in probing depths and an increase
in the probing attachment levels. At the 4th year of assessment for the initially
deep pockets, the reduction in probing depths was significantly greater for the
sites treated with the implant material. In view of the difficult clinical problem
posed by the treatment of teeth with deeper periodontal bone defects, further Key words; periodontai bone defects; im-
research using etther this type of implant material or similar material should be piants; tiydroxyJapatite
considered. Accepted for pubiication 4 July 1991

The current trend in periodontal There have been a number of clinical study was designed to include regular
surgery is to use techniques that con- studies in the use of synthetic alloplastic follow-up visits for scaling and mainten-
.serve periodontal tissue and hicrease the materials as implants in periodontal oss- ance of plaque control.
potential for healing by the formation eous defects. Relatively few of these
of a long lunctional epithelial attach- studies have included control pro-
Material and Methods
ment, new attachment or bone re- cedures. Some ofthe longer term studies
Subjects for the study
generation. These techniques contrast have included surgical re-entry pro-
with previous procedures that were de- cedures during follow-up: whereas re- The subjects for the study were 10 pa-
signed to eradicate pockets by excision entry measurements provide very useful tients aged between 33 and 59 years who
or repositioning of unsupported soft data on hard tissue contour and the had been referred to the Periodontal
tissue and by recontouring of any as- retention of the implant in the bone de- Department of University College and
sociated osseous defects. fects, the secondary surgical procedure Middlesex School of Dentistry, Lon-
The ideal result of periodontal is liable to influence the subsequent fol- don, for the treatment of chronic adult
surgery would be the regeneration of low-up measurements. periodontitis. Their mean age was 42.5
new periodontai ligament attached to The objective of the present study years: there were 7 females and 3 males.
regenerated bone and new cementum. w as to carry out a long-term, controlled, Prior to their admission to the study,
thus achieving a return to the original clinical study into the use of a ceramic a medical history was taken from each
anatomical relationship. However, the hydroxylapatite implant material in the patient to ascertain that they had no
degree of new bone formation is uncer- treatment of periodontal bone defects. systemic disease that might influence
tain even with guided tissue regenera- No further surgical treatment was car- their periodontal condition or cotitra-
tion procedures. ried out after the initial procedures. The indicate penodontal surgery. It was as-
Hydroxylapatite in periodontal hone defects 571

certamed that they were not wearing a fill with a blood clot. The flaps were with a point diameter of 0,62 mm. The
prosthesis or orthodontic appliance. All then sutured over the wound with inter- distance from the enamel-cement junc-
subjects were prepared lo attend for reg- rupted sutures using 4, 0 braided silk. tion (ECJ) to the gingivai margin was
ular follow-up visits. Periodontal dressings** were placed also measured using the same probe.
The clinical criteria for selection were over the surgical area for I week. Subse- All the measurements throughout the
that the patients should have completed quently the dressings and sutures were study were carried out by one e.xaminer
a course of treatment involving root removed and the teeth cleaned and poli- (PNGI, Reproducibility was determined
planing and plaque control, and that shed, A 0,2'%. chlorhexidine gluconate prior to the study for the various meas-
they should have maintamed an e,xcel- mouthwash was prescribed for use 2 x urement criteria by assessing 6 volun-
lent standard of oral hygiene with con- a day for 1 week. teers on two separate occasions with a
sistently low levels of plaque during the Postoperative clinical healing was time interval of at least 60 min between
last few assessments. The duration of satisfactory. There was a tendenc} for the examinations. The"/«reprodticibility
this preparatory phase varied, depend- some of the implanted material to be for measurement by site was 92'Vo for
ing on the response of the patient to the shed during the first few weeks. pocket measurement. 88"/i. for recession
plaque control programme and on the The patients were followed up with of the gingival margins, and 89,5"n for
rate of resolution of the inflammation. scaling and plaque control maintenance the level of attachment.
For admission to the study, each pa- visits for the first 3 months after surgery
tient was required to have at least 2 at 2-4 week intervals, and thereafter at
Analysis of the data
periodontal osseotjs defect.s of similar 3-monthiy intervals.
radiological appearance to be used for The data for the test and control defects
test and control sites. Where a greater were ordered separately. It was con-
nttmber of lesions were present, these Clinical assessments
sidered that the initial depth of pockets
were also tised in the study. The subjects The initial assessment of the periodontal would influence the response to treat-
gave mformed consent to participate in condition of the patients was carried ment. Inspection of the range of meas-
the project. oul after the root planing and plaque urements for the original data indicated
control phase. Thereafter during the that the baseline figures could be div-
study further measurements were per- ided into three categories: shallow
Surgical procedures and maintenance
formed at six months and at 1,2.3 and pockets ( < 3 mm), moderate pockets
Prior lo periodontal surgery, random 4 years. (3-6 mm I and deep pockets ( > 6 mm).
allocation was used to assign the im- At the above titne intervals, the meas- For each of the assessment criteria and
plant or control procedure lo the vari- urements were made for each osseous at all the time intervals, the data were
ous experimental sites. defect, at all the involved sites, along tabulated with respect to the basehne
The surgical treatment was carried the vertical axes of the teeth. As the categories of shallow, moderate and
oul under regional or infiltration local bases of the pockets were found to be deep pockets. The mean values for these
analgesia using 0,2"ii lignocaine with ad- very irregular, the meastirements were grouped categories of pocket depths for
renaline 1:80.000, A conservative in- made at multiple sites for each bone each patient were taken as the units for
verse bevel incision was u.sed retaining defect: at the interproximal surfaces the statistical analysis (Blomqvist 1985),
as much of the gingival tissue as poss- with the probe resting against the con- Statistical analysts was carried out
ible, .'\ny remaining deposits were care- tact points, at the line angles, at the using the paired Student r-test to com-
fully removed, and the exposed cemen- points of maximum convexity of the pare test and control procedures, and
tum surfaces were planed with a curette root and on multirooted teeth at the the Multiple Range Test for the longi-
until they felt smooth and hard. The entrances to the furcations. Single tudinal changes within procedure (Dun-
bone defects were curetted to remove rooted teeth thus could potentially be can 195.S),
granulation tisstte. The surgical area measured al five sites on both vestibular
was then washed with physiological sa- and oral aspects, w^hereas lower moiar
line and carefully inspected to ensure teeth could be measured at 7 sites on Results
that the procedures had been completed both aspects according to the nurnber A total of 58 test defects and 59 control
satisfactorily. The test sites were treated of sites involved. defects were treated. At the test and
by the implantation of sintered hy- The measurement criteria for plaque control defects there were 146 and 152
droxylapatile particles*. It was found was based on zero being scored for the shallow siles. 216 atid 241 moderate
that the most satisfactory method of absence of plaque and one being scored sites and 140 and 133 deep sites, respec-
inserting the material into the defect was for each surface where plaque was pres- tively. The objective had been to achieve
by mixing it to a paste wilh some of the ent. Similarly, gingivitis was scored zero defects with similar degrees of t!i\olve-
patient's own blood, which was with- or one on the basis of whether lhe gin- ment for test and control procedures,
drawn from the operative site in a sy- giva showed bleeding within 20 s after by randomly allocating the treatments
ringe. The resultatit mixture was taken probing at the various sites. Pocket to matched pairs of defects. There were,
lo the bone defect on the blade of a measurements were carried out with a however, found to be minor differences
curette. The control defects were left to Williams graduated periodontal probe* in the distribution of the seventy of de-
fect between the test and control pro-
cedures at baseline. E,g,. considering the
** Coe-Pak. Coe Laboratories. Chicago.
gingival recession data at both shallow
' Durapatite (PeriograO. Sterling-Winthrop. atid deep sites, the mean value for re-
Guildford. UK, • Hu-Friedv. Chicaeo. USA, cession was greater at the sites to be
572 Galgiit et al.

treated by the test procedure than by control sites which were significant at
Results for probing pocitet depths
the control procedure (Table 1), This the />< 0,05 level (Table 5), At 6 months
finding also in turn influenced the For both the test and conttol surgical after surgery, the mean loss of probing
values for loss of probing attachment at procedures at the follow-up assesstnents attachment for both experimental pro-
baseline there being a trend for more after treatment compared with the base- cedures was approximately 0,5 mm.
loss of attachment at future test than line measurements, there were decreases subsequently there w,ere further losses
control sites iTabIc 5), Further analysis in the probing pocket depths (Table 3), of attachment for test and control pro-
was carried out to provide data of These decreases were not statistically cedures, the results at 4 years after
change from baseline for all the meas- significant for shallow pockets, but were surgery for loss of probing attachment
urements to compensate for the unequal significant for moderate and deep being respectively 0,90 mm and 1,09 mm
distribution at the pre-surgical a,ssess- pockets (/*<(},01), .^t the control sites (Table 6|,
ment (Tables 2. 4 and 61, for both the moderate and deep pockets ln contrast, for both moderate and
the post-surgical mean values showed deep pockets, there was a gain in prob-
relatively minor changes during the fol- ing attachment after surgery lor the test
Results for gingivai recession low-up period of the study. At those and control procedures. For the moder-
After surgery at each of the assessment sites treated with the implanl material ate pockets, this gain was significant at
intervals for both the tesi and control however for the initially moderate and the P<0,05 probability level for some
procedures, there was a statistically sig- the initially deep pockets there was a time intervals, whereas for the deep
nificant increase in gingival recession trend for further reductions in probing pockets this gain was significant at the
compared to basehne (Table 1). the pocket depths during the follow-up /'<0,01 level at all post-operative as-
probability levels with the multiple period. sessments. During subsequent foiknv-up
range test being either <0,05 (indicated The redtictions in mean probing at the control sites, there was a trend
by the broken lines) for some of the pocket depths at the various time inter- for the initial gain to diminish: however
control data or <0,01 (indicated by the vals for the two procedures ranged from at the test sites the gain was maintained
continuous lines) for the remainder of 0,17 mm to 5,00 mm. being greatest for or increased
the comparisons. In general, there was the initially deep pockets (Table 4), Comparing the results of the 2 pro-
more recession for deeper initial pockets Comparing the results for the two pro- cedures (Table 6). it was found that, at
than for the shallow ones, the initial cedures il was found at the fourth year the 4-year time interval for the change
postoperative increase in recession assessment that for the deep pockets the in the attachment level after surgery, the
ranging from 0,73 mm for shallow in- mean reduction in probing pocket depth difference between the test and control
itial pockets to 1,48 mm for the deep for the test procedure of 5.00 mm was procedures for the initially deep pockets
initial pockets (Table 2), At successive significantly greater than the mean approached statistical significance {P=
follow-up assessments the change in re- value of 4,20 mm for the control pro- 0 058). the difference being just over I
cession tended to increase progressively cedure (/'<0,U5), mm.
being greatest at the four year assess-
ment, when the values ranged from 1,21
mm to 1,95 mm. As can be seen in Table Results tor the ioss of probing attachment Discussion
2. there was no statistical!)' significant from ECJ
The use of synthetic implant materials
difference between test and control pro- For shallow initial depths of pockets to overcome some of the difficulties m
cedures at any of the time intervals (Stu- there were post-operative losses in prob- treating osseous delects caused by
dent's /-test. /-'>0,05), ing attachment level at both the test and periodontal disease has been investi-

Table I Mean and standard devialion for recession from EC',1 for fO patients at lhe various time intervals Tor different initial depth of pockels
and tor Ies! and control procedures
ShaDow initial < ? mm Moderate initial ? 6 mm Deep initial > 6 mm
Pockels
Time Test mean Control mean Test mean Control mean Test mean Control mean
inici'vul fSD) (SD) fSDl (SD) (SD) (SD)
Baseline 0,45 0,22 0,50 0,46 0,70 0,35
tO.27) (0,20) (0,5.S) (0,.54) (0,71) (0,55)
b months - 1,03 - 1,54 ^ 1,23 r- 2,18 r 1,63
(0.57) (0,4."^) (0,86) (0,59) 1 (1-13) 1 (1,05)
I yeiir 1,24 , 0,98 1,35 1,22 2,04 1,70
(0,641 1 (0,631 1 (0,67) (0,69) (0,K9) 1 (1,21)
2 year^^ 1,30 1,13 i 1,49 1,26 1 1,63
(0,59) (0,4.s) (0,67) (0,50) (1,19) ! (1,43)
3 years 1,46 1,.16 1 1,66 1,49 2 40 1,90
: ((i.52) (0,.')0) (0,64) (0,74) I (.,21) (1,36)
1
4 years L 1,69 L I,.SO ^ 1,90 - 1,67 L 2,44 ^ 2,31
(0,50) (0,72) (0,60) (0,78) (0,76) (1,36)
Analysis of longitudinal changes with time ^
Data within brackets is signiricantly different lo values m lhe same column outside the brjickets at probabihty levels: |^/'<0.05 and [/'<0.0!.
Hydroxylapatiti- in periodontal bone defi'cts 573

Tattle 2. Mean and standard deviation for change in recession irom ba.seline for 10 patients at the various time intervals for different initiai
depth ol' pockets and lor test and control procedures
Shallow initial < 3 mm Moderate initial 3-6 mm Deep initiai > 6 mm
Pockets
Time Test mean C ontro! meap, Test mean Control mean Test mean Control mean
interval (SD) (SD) (SD) ISD) (SD) (SD)
6 tnonths 0.73 O.SO 1.03 0.77 1.48 1.28
1(1.55) (0.34) ((1.56) (0.30) (0.68) (0.72)
1 year 0.80 0.75 (J.84 0.76 1.33 1 35
(0.57) (0.52) (0.44) (0.27) (0.39) (0.87)
2 years ().«6 0.91 0.98 0.80 1 51 1.28
(0.4X) (0.41) (0.39) (0.24) (0.69) (1.16)
3 years 1.01 1.14 1.15 1.03 1.69 1.55
(0.39) (0.50) fO..34) (0.40) (0.07) (1.04)
4 years 1.24 1.28 1 40 1.21 1.74 1 95
I().51) (11.65) (0.39) (0.54) (0.59) (!.03l
.Atialvsis (ff irijfi'renci'.\ heC'-vccn procfdiirc.
No sisnificani dilTerence al an\- lime internal.

Tahk- .1 Mean and standard dcviaiion for depths of pockets for 10 palients at the \-ariouN time intervals for differenl initial depth of pockets
and tor test and control procedures
Shallow inittal < 3 mm Moderate initial 3-6 mm Deep initial > 6 mm
Pockets
Time Test meat! C oiiiro! meari Test mearj C ontrol mean Test mean Control mean
interval (SD) (SD) (SD) ISD) (SD) (SD)
Baseline ^ 1.77 3.80 3.69 7.40 7.1(1
10.16) (0.17) (0.30) (0.32) 10.91) (0 61)
6 months : 1.59 1 1.44 - 2.09 ^ l.9y - 2.98 ^ 3.02
1 (0.25) 1 (0.41) (0.76) (0.41) (0.71 1 (0.79)
1 year 1.64 1.56 2.12 2.15 3.0" 3.37
(0.30) (0.36) (0.53) (0.3U (0.69) (O.Sl)
2 years 1.43 1 92 1.95 2.69 3.03
! ' • "

(0.3.1) (0.32) ((1.55) (0.56) • (1.10) (1.181


3 yca)".s 1.52 1.40 1.K8 ; 2.50 2.S9
1 IU.50) t0.51) • (0.6(1) (0.5 M (0.88) (0.97!
1
4 years - 1.42 - 1.58 - 1.78 - 2.19 - 2.39 - 2.90
(0.401 (0.75i (0.36) (0.76) (0.701 (1 12)
.4i}ah.^i.^- <tf longilttdiih
ii changes wUh time
Data within brackets is signficantly different to data in the same coiumn outside the brackets at probabilit\ levels: i P- 0.05 and [/•< 0.(11,

Tiihie 4. Mean and standard deviation for change I reduction! in pocket deplhs from baseline for 10 patients at the \ariou> time intervals lor
differenl initial depth of pockets and lor test and control procedures
Shallow initial Moderate mitial 3-6 mtii Deep initial > 6 mm
Pockets
Time Test mean Control mean Test mean Control meat) Test mean Control mean
ititerval (SD) (SDi iSD) (SD) ISD) (SD)
6 months O.P 0.33 1.72 1.71 442 4.08
(0.24) (0.39) (0.60) (0.50) (1.28) (0.88)
1 year 0.12 0.20 1.68 1.55 4.33
(0 26) (0.39) (0.44) (0.48) (!.O1) (0.70)
2 years O.J3 0.44 1.89 l."4 4.70 4.07
(0.32) (0.34) (0.38) (0.56) (1.2X) (1.22)
3 years 0.24 0.37 1.96 1.81 4.90 4.21
(0.57) (0.5S) (0.67) (0.58) (0.92) (1.06)
4 years 0..34 o.ts 2.02 1.50 5.00 * 4.20
(0.42) (0.83) (0.56) (0.71) (0.81) (0.83)
Analysis of ditffri'ncc.s between proci'dure
* Statistically significant difference (/*<
574 Galgut er ai.

Tahie 5. 'Mean mid sljndard devijtion foj loss o^ attachment for 10 patients at the various lime intervals for dilTerent initial depth ol" pockets.
and for test and control procedures
Shallow initial < 3 mm Moderate initial 3 6 mm Deep initial > 6 mm
Pockets
Time Test mean Control mean Test mean Control mean Test mean Control mean
interval (SD) (SD) (SD) (SDi (SD) (SD)
Baseline 2.21 1.99 4.31 4.15 8.10 7 45
(0.31) (0.22) (0.721 (0.56) (1.09) (0.99)
6 months ' - 2.46 3.62 - 5,16 p 4.65
(0,70) ! (0.70) (1.06) (0.42) (0.96) (1.29)
1 year 2.S9 2.54 r- 3.47 3.36 5.10 5.07
(0.63) (0.90) ; (0..-9) (0.79) (096) (1,45)
2 years 2.46 ; 3.40 L 3.2! 4.91 4,67
(0.56) (0.65) (0.78) (0.79) (1.21) (1,78)
3 years 2.9S 2,76 i_ 3.50 3.37 4.90 4,79
(0.65) J (O.M) (0..56) (t).92) (0,89j (1,48)
4 years "^, 1 I •- 3.08 3.69 3.86 - 4.83 - 5,21
(0.56) (1.35) (0.53) (1.32) (1.07) 11.80)
Ana!vsL\ of longitudinal chau^cs \\i!h time ^
Data wkhin brackets is signiHcantly different to data in the same column outside the brackets cii probability levels: |_P<(t,05 and |

Table 6. Mean and standard deviation for change Igam} in atlachmenl fnim ECJ from basehne for IU patients al the various intervals \o\
different initial depth of pockets and for lest and control procedures
Shallow initial < 3 mm Moderale miiial 3 6 mm Deep initia 1 > 6 mm
Pockets
Time Test mean Control mean Test mean Control mean Test mean Control mean
m(er\a] (SD) (SD) (SD) (SD) (SD) iSDl
6 months -0.56 - 0.48 0.68 0,93 2,94 2 SO
(0.69) 10.65) (0.62) (0.55) (1,60) (117)
1 year -0.68 -0,55 0.84 0,79 3,00 2,38
(0,59) (0,881 (0.52) (0.59) (1,12) (0,S8)
2 years -0,52 - 0.47 0 90 0,94 3 19 2.79
(0.61) (0.59) (0.53) (0,51) (1.33) ( 1.4?)
3 years -0.77 -0.7S 0,81 0,78 3.21 2.66
(0.64) (0.80) (060) (0,63) (0.82) (1.05)
4 vears -0.90 -1.09 0,62 0,29 3.27 * 2.24
(0.66) (1.35) |O,5«) (0,90) (1.16) (0.96)
* Approaching statistically significant difference (P = O.O58).

gated by a number of workers. In a ture have been introduced, it being con- include a re-entry procedure at any
recent review, it was found that varying sidered that the presence of pores and stage; secondly the defects were meas-
degrees of success had been reported in interconnections might enhance the de- ured at defitied sites and these sites were
clinical studies of treatment of perio- position of new bone: however relatively analysed independently according to the
dontal bone defects with alloplasts few studies have reported on the use of initial pocket depths within subjects;
(Waite & Galgut 1987). The implant porous materials up to the present. thirdly the present research was con-
materials that have been used mosl ex- The present study represents a 4-year tinued for a 4-year period; and fourthly
tensively are hydroxylapatite and trica!- study of patients who had periodontitis a densitometric radiographic study was
cium phosphate; both materials have with osseous defects, which were treated undertaken on a sample of the radio-
been found to be well tolerated by the surgically by curettage of the defects at graphs over a two-year period this re-
local tissues when used m periodontal open flap surgery for the control pro- port being the subject of another paper
bone defects. The local response to the cedures, or the same treatment com- (Galgut et al. 1991).
implant varies according to its chemical bined with and hydroxylapatite implant
composition, its structural character- material for the test procedures. Pre-
istics for example the density and po- vious research on the same subject has Recession
rosity, and the type of host tissue adjoin- been reported (Ytikna et al. 1984; Yu- A significant increase in gingival re-
ing the implant. It has been found that kna et al. 1985; Yukna 1989; Yukna cession was found after both surgical
hydroxylapatite is degraded at a rela- et al. 1989). The present study used a procedures, and there was a gradual
tively slower rate than tricalcium phos- modified protocol; first in order to further increase in recession as the study
phate (Han et al. 1984). Nfore recently, avoid possible interference with the con- progressed. A review by Lindhe & Nym-
implant materials with a porous struc- tinuity of follow-up, this study did not an (1987) concluded that irrespective of
Hydroxylapatite in periodontal hone defects 575

the type of therapy, including non-surgi- treatment (Haiazonetis et al. 1989, absence of inflammatory cells in the
cal procedures, about SO"/, ofthe reduc- Vanooteghem et al. 1987). vicmity of the hydroxylapatite particles,
tion in pocket depth as a result of treat- The findings in the present study that suggesting that ihe material was well
ment can be explained by recession of surgical treatment of initial pockets of tolerated by the tissues. There is no data
the gingival margins. At the commence- less than 3 mm resulted in a significant available to compare the histological
ment of this study, it had been con- mean loss of probing attachment of up amount of new bone formed between
sidered possible that the implant ma- to about I mm is in agreement with sites treated with implant materials and
terial might result in less postoperative other workers (Lindhe et al. 1982, Pihl- control sites treated by curettage alone.
recession, and this would clearly have strom et al. 1983). For the initialK mod- A previous radiographic study into a
been an advantage where aesthetics erate and deep pockets, the implanted sample ofthe bone defects treated in the
were important. However, at the 4-year sites tended to continue to maintain the present study utilised computer aided
assessment, the degree of recession after improvement in probing attachment densitometric measurement. Over the 2-
treatment was similar for both test and levels compared with baseline, or in the year period of the study, the sues treated
control procedures, ranging from 1.2 to case of the deeper pockets to show with the implant material showed a sig-
2.0 m depending on the initial depths of further improvement. However, the nificant gain in the mterproximal height
pockets. Yukna et al. (1984, 1989) also level of probing attachmenl at the con- of radio-opaque substance compared to
found similar mean values for recession trol sites began to deteriorate as the fol- the control sites, as determined by a
postoperatively for both hydroxylapa- low-up progressed. By the 4th year for computerised analysis system. The re-
tite treated sites and controls. It can be sites with initially deep pockets the dif- sults indicated that the radio-opaque
concluded that hydro.xylapatite implant ference between test and control sites implant material was retained within the
material is unlikely to influence the de- approached significance being at the bone defects postoperatively.
gree of recession after periodontal P = 0.058 level. The results of the present study can
surgery. It was of interest that these differ- also be considered m relation to the con-
ences it! probing attachment level for clusions of a review article on perio-
deeper pockets became more apparent dontal therapy by Lindhe and Nyman
Pocket depths
later on in the study. One of the mam (1987). The results confirm the hypo-
in the present study, there was a signifi- objectives of periodontal treatment is thesis that probing attachment loss fre-
cant reduction in probing pocket depth long-term stability of the attachment quently occurs following treatment of
after surgery for all categories of site level, hence the later results in a study sites w ith initially shallow pockets, and
and for both procedures. The reduction are of particular importance. that gain of probing attachment gener-
was greatest for the initially deep Yukna et al. (1984, 1989) did not fmd ally results following treatment of deep
pockets, and this finding is in agreernent that there were any differences in prob- pockets. The authors observe that this
with the review by Pihlstrom et a!. ing attachment levels. The re-entry pro- gain in attachmenl is generally a false
(198?). For the deeper pockets, there cedure at one year after surger\^ in- gain, the dentogingival epithelium dur-
was a trend for further improvement on cluded in most if not all the studies by ing healing migrating close to the orig-
the implanted sites during the follow up Yukna and co-workers may have influ- inal preoperative level oti the root sur-
period. .\l the 4-year assessment for the enced the follow-up measurements. face. The apparent gain in attachment
sites with initially over 6 mm pocket is the result of resolution of gingi\-al
depths, there were significantly shallow- inflammation with collagen fibres re-
er pockets for the implanted compared Implications ot tiie results placing the inflatnmatory infiltrate
with the control defects. Previous 3- and This study has indicated that some of within the tissues. In the present study
5-year studies of hydroxylapatite im- the clinical measurements may be influ- at sites where bone defects have been
plants in periodontal bone defects also enced by the treatment of initially treated with implant materials, the in-
found that there were statistically sig- deeper periodontal bone defects with corporation of the implant particles in
nificant differences between test and hydrosylapatite implatit materials. The the fibrous tissue repair could hypo-
control procedures but only at the later results should be considered in the light thetically aid in supporting the sulcular
periods ofthe study (Yukna et al. J984, of previous studies into histological re- epithelium and junctional epithelium
1989). There seems to be agreement that sponses to such implants. It has been against the root surface and hence in-
differences between the implant treated found that during the early stages after crease the resistance to penetration by
and the control sites are evident mainly surgery hydroxylapatite implant par- the probe.
in the long-term. ticles become surrounded by fibrous The present results should also be
tissue (Froum et al. 1982, Moskow & considered in the light of recent work
Lubarr 1983). Lotiger-term studies have on the use of various membrane ma-
Level of probing attachment shown that after about 6-18 months the terials to guide regeneration of perio-
Iti previous longitudinal studies of particles may undergo localised areas dontal tissue over areas of cementum
periodontal disease, the poor corre- of resorption, and regions were found previously involved by periodontal dis-
lation found between loss of attachment where bone or osteoid material had ease. The objective of the technique is
and such other clinical criteria as pocket formed around the implant particles, in to restrict the proliferation of both epi-
depths, bleeding on probing and gin- one case, a collagenous bone matrix had thelial cells and gmgival connective
gival oedema and colour change empha- enveloped the entire implant {Sapkos tissue and to encourage the prolifer-
sise the importance of long term meas- 1986. Galgut et al. 1990). The appear- ation of periodontal ligament cells into
urement of level of probing attachment ances in these studies were very variable. the surgical wound area by providing a
for assessing the results of periodontal An important genera! fmdmg was an protected site. The various studies have
576 Galgut ci al.

shown a gain of several mm of new des klinischen Attachnientniveaus wurden Duncan. D. B, (1955) The new multiple range
penodontai ligament attachment, how- nach 6 Monaten, 1. 2. 3 und 4 Jahren durch- test. Biometries 2, 1^3.
gefuhrt. Wahrend des t^Intersuchungszeit- Froum, S. J., Kushner, L., Scopp, I. W. &
ever relatively less predictable gain in
raums wurde an alien Zahnflachen mit mitt- Stahl. S. S. (19S2) Case reports. Human
bone height has been found in the rela- leren und llachen Taschen eine signiftkante clinical and histological respon,ses to Dura-
tively short-term studies reported to Reduktion der Sondierungstiele und Zunah- patite implants in intraosseous lesions.
date (Gottlow et al. 1986). The ideal me des klinischen .^ttachmenttiiveaus beob- Journal of PeriiHion!ok)i;r 53. 719 725.
procedure for the treatment of a bone achtet. Fur die initial tiefen Taschen. die mit Galgut. P. N., Verrier, ,L. Waite, L M.. Lin-
defect would achieve a return to struc- Implantatmaterial behandelt wurden. war die ney. A. & Cornick, D. E. R. (i991) Com-
tural integrity of the hard tissue and the Reduktion der Sondierungsttefe zum Zeit- puterised densitometric analysis of inter-
formation of new periodonta! iigament punkt der 4-Jahrestnessung signifikant hoher. proxirnal bone levels in a controlled clini-
attachment. The use of implanted ma- Im Hinblick auf die schwierigen klinischen cal study into the treatment of periodontal
Probieme. die mtt det Behandlung \on tiefen bone defects with ceramic hydroxyapatite
terials irt conjunction with guided tissue
parodontalen Knochendefekten verbunden nnplant material. Journai oi Periodoniolo-
regeneration procedures might be a sub- sind. sollten weitere Untersuchungen entwe- gv 62, 44-50.
ject for future research. der mit diesem oder einetit ahnlicheti Mate- Galgut. P N., Waite, 1. M. & Tinkler, S. M.
rial erwogen werden. B (1990) Histological investigation of the
tissue response to hydroxyapatite used as
Conclusion an implant material in periodontal treat-
Resume
A possible role for the use of hy- ment. Clminil Maleriuls t>. 105-121.
droxylapatite implant tnaterials for the Etude clinique lonirdiee sur 4 ans concernant Gottlow, ,1.. Nyman, S., Lindhe. J.. Karring,
I'yiilisation dun inateruiu pinir grtfje en ceia- T. it Wennstrom, J. (19S6) New attach-
treatment of deeper infrabony defects is
mique d'Indro.Kyapariie daiu le traitement Jt'.v ment formation m human periodontiutn
supported by the present study. During by guided tissue regeneration. Journal oJ
le.^ion.\ ti.^setL^'es parndontales
the latter part of this four year study it Chez 10 patients atteints de parodontite chro- Ciinieal Periodoiilo/ngr 13, 604-616.
was found that itiitial pockets of more nique de I'adulte et presentant des poches Halazonetis, T. D.. Haffajee, A. D. & Socran-
than 6 mm in depth showed a greater intra-osseuses sur plus d'une dent, le traite- sk), S. S (I9S9) Relationship of clinical
degree of reduction in probing pocket ment des lesions test a ete fait par interven- parameters to attachment loss in subsets
depths and an increase in probing tions a lambeaux parodontaux avec greffe de of subjects with destructi\e periodontal
attachment levels. In view of the diffi- particules d'hydrox} apatite; les lesions te- disease. Journal ol Clinical Periodon!oh\^\v
cult clinical problem posed by the treat- moins (control) etaient traitees par les memes 16, 563 56S.
methodes chirurgicafes. mais sans greffe, Au Han. T.. Carranza, F, A. ik Kenney, E. B.
ment of teeth with deeper osseous de-
total. 58 lesions test et 59 lesions temoins ont (1984) Calcium phosphate ceramics in den-
fects, further research using either thts ete traitees. Dans chacune des lesions, des tistry: a re\'iew c^f the literature. Journai o}
type of implant material or similar mesures ont ete pratiquees en certains sites lie.sterii S<ieie!y ol Perh'doniology. Pena-
forms should be considered. determines sur les surfaces dentaires tou- dontal .4hstrael!i 32, SK 106.
chees. ces sites etant consideres pour les enrc- Lindhe. J. & Nyman, S. (19S7) Clinical trials
gistrements ulterieurs comme appartenant a in periodontal therapy. Journal of Perio-
Acknowledgements une des categories suivantes: poches initiales donlal R e s e a r c h 2 2 , 2 1 7 2 2 1 .
peu profondes ( < 3 mm), tnoderees l3-6 mm) Lindhe, J., Socransky. S S.. Nyman, S., Haf-
The authors wish to express their grati- ou profondes ( > 6 mm). Le nombre de sites
tude lo Mrs Christine Tham for her care fajee, A. & Westi'elt, E, (1982) Crittcal
test et temotns etait pour ies sites peu pro- probing depths in periodontal therapy.
and pattence in preparing the typescript fonds (shallow) respectivement 146 et 152, Journal of Clinical Periodomology 9,
for this paper. pour les sites moderes (moderate) respective- 32,3-336.
ment 216 et 241. enfin pour les sites profonds
Moskow, B S. & Lubart; A, (1983) Histo-
(deep) respectivement 140 et 133. Des mesu-
logical assessment of human periodontal
Zusammenfassung res de la recession, de la profondeur des po-
defect after Durapatite ceramic implant -
ches au sondage et du niveau de I'attache au
Eine koturoUierte klinischv 4-.J(tin'cs.^tudii' report of a case. .Journal of Pcric}dontology
sondage ont ete pratiquees a 6 mois et a 1,
iihi'r die Vcrnenclung fines keramisclwn Hy- 54, 455-462.
2. 3 et 4 ans. Pour tous les sites W s'est produit
droxvlapanr-Iiuplantmati't-iat.^ zur Beiuiful- Pthlstrom, B. L . Mchugh. R. B,, Oliphant,
dans les poches ayant itne profondeur initiale
iun^ von put'cKlcfUulcii Knochendelektcn T, H. & Ontz-Campos, C. (19K3) Compari-
moderee ou profonde une reduction significa-
Bei zehn Patienten tnit chrortischer Erwach- son of surgical and nonsurgicai treatment
tive des profondeurs de poches au sondage et
senen-Parodontitis. die mehr als einen Zahn of periodontal disease. Journal of Ciinieal
une augmentation des niveaux d'attache au
mit einer inlraaiveoiarctl Knochetitascheaul- Periodontology 10, 524-541,
sondage au cours de la periode de Fetude.
ueisen muBten. wurden die Testdefektc durch Lors de la 4*"^^ annee d'observation, pour les Sapko.s, S. W (1986) The use of Periograf
eine Lappenoperation mit Implantatioti voti poches mitialetiient profondes. la reduction in periodontal defects. Histologic findings.
Hydroxylapatit-Granulat behandelt. Die des profondeurs de sondage etait significati- Journal of Periodoniology ^1. 7 13.
Korttrolldefekte wurden mit der gletchen vement plus elevee pour les sites traites avec Vanooteghem. R., Hutchens, L. H., Garrett,
Technik. Jedoch ohne Implantation behan- I'hydroxyapatite. Etant donne !e probleme S., Kiger, R. & Egelberg, J. (1987) Bleedtng
delt. Insgesamt wurden 58 Test- und 59 Kon- clinique difficile que pose Ie traitement des on probing and probing depth as indi-
trolldefekte behandelt. Bei Jedem Defekt wur- dents ayant des lesions parodontales osseuses cators of Ihe response to plaque control
den an den einbezogenen Zahnflachen an be- profondes, des recherches ulterieures avec ce and root debridement. Jcmrnal ol Ciinieal
stinimten Stellen Messungen durchgefiihrt- type de matertau devraient etre envisagees. Periodontology 14, 226 230.
Zum Zweck der Einteilung wurden drei Kate- Wane, I. M. & Galgut. P N. (1987) The role
gorten der initialen Taschentiefe gebildet: of clinical implant materials in the surgical
flach ( <.i tnm). mittel (3-6 mm) und tief t > treatment of chronic periodontitis. Ciinieal
6 mm). Bei den Test- bzw. Kontrolinachen References
Materials 2. 293-302.
gabes 146 und 1.^2 flache. 216 und 241 trtittle- Blomqvist. N. (1985) On the choice of com- Yukna, R. A., Mayer, E. T. & Brite, D. V.
resowie 140 und 1.13 tiefe Flachen. Messungen putational unit in statistical analysis. Jour- (1984) Longitudinal evaluation of Durapa-
der Rezessionen. der Sondierungsttefe und tite ceramic as an alloplastic implant in
nal of Climcal Periodontoiogy 12, 873-876.
Hydro.xylapatite in periodontal bone defects 577

periodontal osseous delects after .1 years. to hydroxylapatke grafting versus open Address:
Journal of Pcrtodontotogy 55. 63.1-637. f\dpdehTidt:mi:n{. Journal ofClinual Pcrio-
Yukna. R. A., Harrison, B. G.. Caudill, R. doniotogv 16. 398-402. , „ ,,.
F., Evans. G. H.. Mayer. E. T. & Miller, Yukna, R. A,, Mayer,y E, T, & .Amos S
S MM p' ] " " n
S. (19S5) Evaluation of Durapatite ceramic , ] 989) S-vear evaluation or Durapame cer-
a.s an alloplast.c ™plant in per.odon.al am,c .mplants m penodontal osseous de- f 7
osseous defects. J,»,™/«/7Vr,W»w,,fo^, fees. Journal of Periodontoiogr M ^""'-''^™ «
56.540-547, 540 .S43 ' ' ^'"gm-'-e 0.^ 11
Yukna. R A. (19S9) Osseous deled responses

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