10.59987/ads/2014.3.103-107
Aim. The use of substitute materials is one of the solutions used in periodontology for the reconstruction of intrabony defects. Advances in scientific research gave rise to a new generation of biomaterials of synthetic origin stoichiometrically unstable and therefore really absorbable. Our research is directed precisely towards a biomaterial synthesis, Engipore® (Finceramica, Faenza, Italy) which is a bone substitute of the latest hydroxyapatite-based generation, that possesses chemical and morphological properties similar to those of natural bone in the treatment of infrabony periodontal defects. Aim of this study was to evaluate the efficacy of Engipore® in the treatment of intrabony periodontal defects.
Methods. The study was conducted on 100 parodontopatics patients, which had gingival pockets of at least infrabonies 8/10 mm. The histological evaluation was performed with samples after one year from the graft.
Results. The histological samples collected after one year showed an abundant new bone formation, with mature lamellar bone tissue surrounding the residual particles of Engipore® that appear completely osteointegrated. The surrounding connective tissue shows no signs of inflammation.
Conclusions. The results obtained in our research demonstrated that, after a proper selection of patients and lesions, and applying an adequate surgical technique, this type of biomaterial in the treatment of periodontal defects acts in an optimal manner as a filler inducing the formation of new bone as evidenced by histological examinations.
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Annali di stomatologia
intrabony defects
Histological evaluation of a biomimetic material in bone regeneration after one year from graft
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intrabony defects
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Histological evaluation of a biomimetic material in bone regeneration after one year from graft
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                                                                                                  Original article



    Histological evaluation of a biomimetic material in
    bone regeneration after one year from graft




                                                                                                    i
                                                                                                  al
                                                                                               on
    Michele M. Figliuzzi, DDS, PhD1                        demonstrated that, after a proper selection of pa-
    Rossella De Fazio, DDS1                                tients and lesions, and applying an adequate sur-
    Rosamaria Tiano, DDS1                                  gical technique, this type of biomaterial in the
    Serena De Franceschi, DDS1                             treatment of periodontal defects acts in an optimal
    Delfina Pacifico, DDS1                                 manner as a filler inducing the formation of new




                                                                                      zi
    Francesco Mangano, DDS2                                bone as evidenced by histological examinations.
    Leonzio Fortunato, MD, PhD1
                                                           Key words: biomimetic material, bone regenera-




                                                                        na
                                                           tion, periosteum, intrabony defects.
    1   Department of Periodontics and Oral Sciences,
        Magna Graecia University, Catanzaro, Italy
    2   Department of Biomaterials, Insubria University,   Introduction




                                                             er
        Varese, Italy
                                                           Advances in scientific research gave rise to a new ge-
                                                           neration of biomaterials of synthetic origin stoichiome-
    Corresponding author:                                  trically unstable and therefore really absorbable (1).
    Michele M. Figliuzzi


                                                      t    In recent years, studies in tissue regeneration in pe-
    Department of Periodontics and Oral Sciences,
    Magna Graecia University, Catanzaro
                                                   In      riodontology had a significant development of synthe-
                                                           tic materials, starting from hydroxyapatite. In particu-
    Via Tommaso Campanella 115                             lar, materials able to mimic the functions of the bone
    88100 Catanzaro, Italy                                 have been studied, and then trigger the mechanisms
    E-mail:raass@hotmail.it                                of their guided bone regeneration (1-3). However, in
                                                  ni
                                                           the literature, studies of hydroxyapatite-based bioma-
                                                           terials reported conflicting data. Some authors have
    Summary                                                shown that the hydroxyapatite implanted into the bo-
                                    io

                                                           ne induces the formation of new bone, which adheres
    Aim. The use of substitute materials is one of the     chemically to the surface of the biomaterial without
    solutions used in periodontology for the recon-        the interposition of fibrous tissue (4-8).
    struction of intrabony defects. Advances in scien-     Other authors have shown that hydroxyapatite acts
                           iz



    tific research gave rise to a new generation of        well as a filler, inert, but would always surrounded by
    biomaterials of synthetic origin stoichiometrically    fibrous tissue with no evidence of osteogenesis (9-12).
    unstable and therefore really absorbable.              By literature, a conflicting point was the “Geometry of
           Ed




    Our research is directed precisely towards a bio-      Surface” (osteoinductive geometric configuration) of the
    material synthesis, Engipore® (Finceramica,            biomaterial used. As demonstrated by the studies of Ri-
    Faenza, Italy) which is a bone substitute of the la-   pamonti et al. (13), the geometry of the surface is criti-
    test hydroxyapatite-based generation, that pos-        cal for the shape, locomotion and cell differentiation. In
    sesses chemical and morphological properties si-       particular, the porosity and crystallinity of a biomaterial
    milar to those of natural bone in the treatment of     confer a proper reabsorbability and differentiation (14).
IC




    infrabony periodontal defects. Aim of this study       Our research is directed precisely towards a biomate-
    was to evaluate the efficacy of Engipore® in the       rial synthesis, the Engipore®, which is a bone substi-
    treatment of intrabony periodontal defects.            tute of the latest generation hydroxyapatite-based
    Methods. The study was conducted on 100 paro-          that possesses chemical and morphological proper-
C




    dontopatics patients, which had gingival pockets       ties very similar to those of natural bone. This type of
    of at least infrabonies 8/10 mm. The histological      structure and its morphological and microstructural
    evaluation was performed with samples after one        characteristic allows this material, just applied in situ,
    year from the graft.                                   to absorb the full thickness bioactive proteins and
©




    Results. The histological samples collected after      growth factors present in the clot and releasing gra-
    one year showed an abundant new bone forma-            dually, generating a rapid vascularization and making
    tion, with mature lamellar bone tissue surrounding     more effective osteogenesis (15-17).
    the residual particles of Engipore® that appear        It has high osteoconductive properties and kinetics of
    completely osteointegrated. The surrounding con-       osseointegration of 9-18 months (2,3,18). It has ex-
    nective tissue shows no signs of inflammation.         cellent adaptability and machinability and volumetric
    Conclusions. The results obtained in our research      rendering, making it ideal for many applications. They

    Annali di Stomatologia 2014; V (3): 103-107                                                                   103
    M.M. Figliuzzi et al.


    include: sinus lifts, periodontal defects and peri-im-    anesthesia (Mepivacain plus Adrenalin 1:100.000,
    plant dehiscence (19, 20). Depending on the size of       Pierrel Italia), according to Cortellini et al. (1999), an
    the defect, it can be taken advantage by the amount       intra-sulcular incision with a papilla preservation tech-
    of material required limiting waste, as the product is    nique was made by means of a lancet (Beaver 64,
    available in different packaging: in flakes from 0.5-1    Becton, Dickinson & Co, USA) between the mesial




                                                                                                          i
    mm in diameter, 0.5 g and g 2x0.5 easily shaped into      tooth and the distal one. Flap was raised at a split




                                                                                                        al
    blocks of 10x10x10 mm and from 10x5x5 mm.                 thickness. Granulation tissue was removed with ultra-
    The aim of this work was to evaluate the efficacy of      sonic tools and curettes (Fig. 2).
    Engipore® in the surgical treatment of infrabony pe-      Once the defect depth was measured, root condition-




                                                                                                     on
    riodontal defects.                                        ing with tetracycline 0.5% was performed. In addition,
                                                              a biomaterial was adapted Engipore® (Fig. 3). No
                                                              membrane was used and, after filling the defect, the
    Materials and methods                                     flap was coronally positioned and closed by means of




                                                                                           zi
    This study was conducted on 100 patients (40 male
    and 60 female) affected by periodontal disease which
    presented at least one infrabony defect.




                                                                            na
    Defects presented the following characteristics: pure
    2- or 3-wall defects (radiographic intrabony compo-
    nent >4 mm), probing pocket depth (PPD) >6 mm,
    defect angle >30°, mobility of the tooth less than gra-




                                                                 er
    de 1-2.
    Patients were enrolled in a Department of Periodon-
    tics and Oral Sciences, Magna Graecia University,
    Catanzaro, Italy and was approved by the Ethical
    Committee (n.997 del 17/09/2010).


                                                        t
                                                     In
    The present study was performed following the princi-
    ples outlined of the Declaration of Helsinki on experi-   Figure 1. A preliminary X-ray was taken with the parallel
    mentation involving human subjects. All enrolled pa-      cone technique.
    tients signed and informed consent form after receiv-
    ing through oral and written information about the
                                         ni
    procedures and treatment plan.

    Inclusion criterium was:
                                io

    Age >18 years
    Exclusion criteria were:
    Scarce oral hygiene;
    Smoking;
                            iz



    Systemic disease or conditions that could influence
    the outcome of therapy and/or contraindicating
    surgery;
          Ed




    Previous periodontal surgery;
    Chronic NSAIDs assumption;
    Allergy to the used materials;
    Drugs use as nifepidine, steroids, allantoin, estro-
    gens, cyclosporine, bisphosphonates;                      Figure 2. Vision of the bone defect after preparation of the
    Pregnancy.                                                flap.
IC




    Selected patients underwent a non-surgical periodon-
    tal treatment (i.e., full-mouth scaling and root plan-
    ning). After three months, patients were re-evaluated
C




    and the need of periodontal surgery was confirmed.


    Surgical Procedure
©




    Patients were given an antibiotic therapy (Amoxicillin
    and Clavulanic Acid 1 g, 2 times a day for 6 days,
    starting the day before the surgery) and a local anti-
    septic therapy with Chlorhexidine 0.2% rinses for 10
    days. Before surgery, a preliminary X-ray was taken
    with the parallel cone technique (Fig. 1). After local    Figure 3. Defect filled with the biomaterial.

    104                                                                           Annali di Stomatologia 2014; V (3): 103-107
    Histological evaluation of a biomimetic material in bone regeneration after one year from graft


    mattresses sutures (Poliglycolic Acid, Distrex Spa             Results
    Italia). In all cases a periodontal dressing was posi-
    tioned. After 10 days, periodontal dressing and su-            Histological samples, one year after the graft (Figs. 6-
    tures were removed and patients were visited to eval-          10), showed abundant bone formation, with mature
    uate healing (Fig. 4).                                         lamellar bone tissue surrounding the residual parti-




                                                                                                           i
    One year after grafting, a bone core was taken with a          cles of Engipore® that appear completely osteointe-




                                                                                                         al
    diameter of 2 mm at the graft site, under local ane-           grated. The surrounding connective tissue shows no
    sthesia (Fig. 5). The tissue samples were then sent at         signs of inflammation.
    a Department of Pathology performing histological




                                                                                                      on
    analysis. The histological material maintained under
    4% formalin. Than it was subjected to cuts of thick-           Discussion
    ness 4-8 mm by microtome. Each section was colo-
    red by toluidine blue.                                         In the present study, we wanted to evaluate the abi-
                                                                   lity of integration of a biomimetic material of last ge-




                                                                                               zi
                                                                   neration, containing hydroxyapatite (21).
                                                                   The hydroxyapatite used in this search has morpholo-
                                                                   gical and chemical properties very similar to those of




                                                                                 na
                                                                   natural bone. In fact, it has a porosity that reaches
                                                                   90% of its volume in macropores with a range of 200-
                                                                   500 μm and pores of interconnection in the range of
                                                                   80-200 microns. Thanks to its porosity, Engipore ad-




                                                                      er
                                                                   sorb physiologic fluids so that cytokines and growth
                                                                   factors permeate in full thickness the material al-
                                                                   lowing bone forming cells to colonize and differentiate
                                                                   inside.



                                                            t
                                                         In
    Figure 4. Suture.
                                                  ni
                                    io
                           iz
          Ed




                                                                   Figure 7. Bone core.
    Figure 5. Healing of the soft tissues at 6 months.
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©




                                                                   Figure 8. Presence of newly formed bone which surrounds
    Figure 6. Vision Clinic of bone core performed at 6 months.    some Engipore particles.

    Annali di Stomatologia 2014; V (3): 103-107                                                                        105
    M.M. Figliuzzi et al.


                                                                pamonti (13), allow this material, just applied in situ,
                                                                to absorb the full thickness bioactive proteins and
                                                                growth factors present in the clot and releasing gra-
                                                                dually, generating a rapid vascularization and making
                                                                more effective osteogenesis (15,23,24). It has high




                                                                                                              i
                                                                osteoconductive properties and kinetics of osteointe-




                                                                                                            al
                                                                gration of 9-18 months (25-27).
                                                                In addition to the material used, we want to emphasi-
                                                                ze the importance that the surgical technique has in




                                                                                                         on
                                                                these types of interventions, which must be minimally
                                                                invasive. The surgery was performed using the partial
                                                                thickness flap.
                                                                This ensured adequate spraying of the surgical site
                                                                throughout the duration of the treaty and allowed the




                                                                                               zi
                                                                suture anchor with subperiosteal guaranteeing the
                                                                absolute stillness of the flap, a key condition to get a
                                                                good recovery. Finally, it extolled the reparative and




                                                                               na
                                                                regenerative properties of bone tissue and perio-
                                                                steum, a locus of totipotent stem cells (26,27).
                                                                Also the selection of the defects could be decisive in
                                                                exalting the regenerative capacity of sites: those with




                                                                  er
                                                                3 remaining walls are healed better than the sites
                                                                where the residual walls were 2 (28). The histologies
                                                                performed have shown bone formation around the
                                                                particles of inert biomaterial.



                                                          t
                                                       In       Conclusions

                                                                Histological observations testify the excellent biocom-
    Figures 9-10. Not necrosis or inflammatory reaction, the    patibility and good osseointegration properties of the
                                           ni
    graft material was almost completely reabsorbed and were    biomaterial used in connection with the newly formed
    obvious signs of osteogenesis.                              bone. The intimate relationship between the particles
                                                                of the alloplastic material and the newly formed bone,
                                 io

                                                                in its various stages of formation and mineralization,
                                                                allows to assert the ability of the osteoconductive ma-
                                                                terial, that provide the scaffold for osteogenic recon-
                                                                structive process.
                            iz



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          Ed




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    Annali di Stomatologia 2014; V (3): 103-107                                                                                               107
