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Table of Contents   
ORIGINAL RESEARCH  
Year : 2011  |  Volume : 22  |  Issue : 4  |  Page : 511-516
Use of periosteal membrane as a barrier membrane for the treatment of buccal Grade II furcation defects in lower molars: A novel technique


1 Department of Periodontics, Teerthanker Mahaveer Dental College and Research Center, Moradabad, India
2 Department of Periodontics, King George Medical University, Lucknow, Uttar Pradesh, India

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Date of Submission16-Dec-2009
Date of Decision18-Nov-2010
Date of Acceptance14-Dec-2010
Date of Web Publication26-Nov-2011
 

   Abstract 

Objective : To use the periosteum as a barrier in treatment of buccal Grade II furcation defects of lower molars.
Materials and Methods : This technique was performed on 12 patients with bilateral buccal Grade II furcation defects of lower molars. On a random basis, one furcation defect of each pair was selected for the control group and other for the experimental group. Debridement was done in the defect area in both groups. In the control group, after debridement, mucoperiosteal flap was sutured back. In the experimental group, after reflection of the mucoperiosteal flap, a portion of the periosteum along with a layer of connective tissue (periosteal membrane) was incised and mobilized in the defect area for defect coverage as a barrier, and then the periosteal membrane and mucoperiosteal flap were fixed with suture, respectively. Horizontal dimension of the furcation defect was the primary outcome measure. Gingival index, probing attachment level (PAL), and vertical dimension of furcation defect were the secondary outcome measures. Clinical parameters were registered at baseline and at 6 months.
Results : Every clinical parameter was improved by surgery. Significant gain in PAL as well as horizontal and vertical dimensions of the furcation defects was found.
Conclusion: This periosteum displacement technique is effective for the treatment of buccal Grade II furcation defects of lower molars.

Keywords: Barrier membrane, grade II furcation involvement, guided tissue regeneration, periosteal membrane, periosteum

How to cite this article:
Verma V, Saimbi C S, Khan M A, Goel A. Use of periosteal membrane as a barrier membrane for the treatment of buccal Grade II furcation defects in lower molars: A novel technique. Indian J Dent Res 2011;22:511-6

How to cite this URL:
Verma V, Saimbi C S, Khan M A, Goel A. Use of periosteal membrane as a barrier membrane for the treatment of buccal Grade II furcation defects in lower molars: A novel technique. Indian J Dent Res [serial online] 2011 [cited 2019 Sep 18];22:511-6. Available from: http://www.ijdr.in/text.asp?2011/22/4/511/90280
The evidence of effectiveness of guided tissue regeneration (GTR) for furcation defects have been reviewed systematically. GTR was consistently more effective than open flap debridement (OFD), reducing horizontal furcation depths, horizontal and vertical attachment levels and pocket depths for mandibular Class II furcation defects. However these improvements were modest and variable. [1] Periosteal membrane is an attractive alternative to existing barrier membrane since they are biologically accepted. Moreover, the animal studies and clinical trials have shown that the periosteum has the potential to stimulate bone formation when used as a graft or barrier membrane. Periosteum samples taken from the chick embryos have been demonstrated with an osteogenic capacity in vitro. [2] Free periosteal grafts taken from the tibia in the rabbits have shown the osteogenic potency when placed in the anterior chamber of the eye, in the capsule of the kidney, and in the donor site of the tibia. [3]

Osteogenic and growth capacities of the free tibial periosteal graft in cleft lip and palate has been reviewed, and ossification of the periosteal graft has been confirmed. [4] Free autogenous periosteal graft taken from the palate has shown the evidence of defect fill and improvements in pocket depths in Class II furcation defects and interproximal bony defects, when placed as a barrier membrane. [5],[6] The use of the cultured periosteum taken from the mandibular body of adult hybrid dog has shown evidence of regenerating periodontal tissues in class II and class III furcation defects. [7] Case reports of periosteal displacement used a barrier in periradicular surgery have shown early remission of clinical signs and symptoms and successful healing. [8] A new technique of periosteoplasty (Periosteum eversion technique) was described by Gaggl et al. [9] In this technique, periosteal membrane was everted, and side opposite to cambium layer of periosteum is juxtaposed to recession area in the anterior teeth.

Our clinical study was undertaken to evaluate the efficacy of periosteal membrane as a barrier membrane in maintaining its vascular supply in buccal Grade II furcation defects in lower molars.


   Materials and Methods Top


The present study was powered to detect clinically significant difference (δ) in furcation defect fill of 0.5 mm horizontally using α = 0.05, a power = 80%, and a σ Of 0.53 mm obtained in a previous study from this group. [10] Calculations were performed using PS Power and Sample Size Calculation Software (version 3.0,January 2009 http://biostat.mc.vanderbilt.edu/twiki/bin/view/Main/PowerSampleSize). A sample size of 11 pairs of patients was needed to accomplish the study. As my study design was through a split mouth approach using bilateral buccal grade II furcation defects, a single patient had both, a control site and an experimental site in this study design. Hence, 11 patients were needed to put the study in effect. 20 patients were assessed for eligibility. 12 patients were enrolled for the study. The study was conducted in 12 healthy subjects (7 male and 5 female) with a mean age of 37.5 ± 5.99 years (Range 28 to 49 years) [Chart 1] and [Table 1]. Patients having at least one pair of bilateral buccal grade II furcation defects of lower molars were selected from outpatient department of Periodontics, King George Medical University, Lucknow (Uttar Pradesh), INDIA.
Table 1: Baseline demographic and clinical characteristics of the patients enrolled in the study

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Inclusion criteria were as follows:

  • Selected subjects were not under any medication during 1 st month before surgery.
  • Periodontal probing depth (PPD) at mid furcation area was 5 mm or more.
  • Third molars were excluded in the study.
  • Patients had a good oral hygiene.
  • Patients were free of any systemic disease.




Patients were enrolled in the study by Professor Saimbi C.S. who had verified the inclusion criteria and assigned the patients to treatment.

On a random basis, one furcation defect from each pair was selected for the control group and the opposite side furcation defect for the experimental group. Randomization was performed by allotting the left side selected furcation defect to the experimental group and the right side to the control group to 1 st enrolled patient, followed by just opposite to next enrolled patient. This alternate allotting was done to every next enrolled patient. Horizontal dimension of the furcation defect was the primary outcome measure. Gingival index, probing attachment level (PAL), and vertical dimension of furcation defect were the secondary outcome measures. Clinical parameters were registered at baseline and at 6 months by a blinded examiner.

Each patient was instructed about good oral hygiene practices, scaling and root planning was performed under local anesthesia, and occlusal adjustment was also done in selected patients requiring it. All patients achieved effective plaque control prior to entering the surgical phase. After this initial phase of treatment, the presurgical baseline soft tissue parameter, i.e, PAL, was measured with the standardized UNC-15 probe and a customized grooved acrylic stent. Gingival index (Loe and Silness, l963) [11] was also recorded for the facial aspect.

In both the groups, following local anesthesia, crevicular incisions were made starting one tooth distal to the tooth being treated, and extended a minimum of two teeth mesially. To gain adequate access, vertical releasing incisions were performed two teeth anterior to the tooth being treated. Full thickness mucoperiosteal flaps were reflected buccally. The granulation tissues were curetted out, and the exposed root surfaces were thoroughly planed. After debridement, the hard tissue parameters were registered with the UNC-15 probe. Vertical component of defect was measured from the cemento enamel junction (CEJ) to the deepest point of the vertical extent of the defect. Horizontal component of the furcation defect was measured from a probe tangential to the root surface, to the horizontal extent of the defect.

In the control group, the mucoperiosteal flaps were replaced without placement of any barrier membrane, and secured with interrupted interdental suturing using 3-0 black braided silk suture [Figure 1]and [Figure 2]. In the experimental group, the osseous defects were completely covered by an autogenous periosteal membrane maintaining its vascular supply. The periosteal membranes were incised from the mucoperiosteal flap by two horizontal and one vertical incision below the mucogingival junction (MGJ). 1 st horizontal incision was given below the MGJ and mesial to the tooth being treated according to size of furcation defect of the tooth being treated, following which the periosteal membrane was dissected from the submucous connective tissue. 2 nd horizontal incision was given below and parallel to the 1 st horizontal incision. A vertical incision was then given mesial to the horizontal incisions to separate the periosteal membrane mesially, while the periosteal membrane remained attached distally maintaining its vascular supply. The periosteal membrane was mobilized and placed over the exposed furcation defect so that it covered at least 3 mm alveolar bone apical to the defect, and extended coronally at least 1 mm beyond the gingival margin of the flap. Periosteum contains two layer: An outer fibrous layer and an inner cambium layer, which is adjacent to bone. The periosteal membranes were placed such that the cambium layer juxtaposed to the exposed furcation and periosteal membranes were secured with absorbable 5-0 vicryl suture. The flaps were then sutured back as in the control group [Figure 3], [Figure 4], [Figure 5], [Figure 6] and [Figure 7].
Figure 1: Furcation defect probing at baseline during surgery (control group)

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Figure 2: Furcation defect probing during re-entry surgery (control group)

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Figure 3: Furcation defect probing at baseline during surgery (experimental group)

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Figure 4: After autogenous periosteal membrane mobilization (experimental group)

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Figure 5: After suturing the mucoperiosteal flap and autogenous periosteal membrane with protruding edge seen coronally beyond the gingival margin (experimental group)

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Figure 6: Diagrammatic representation of the periosteum displacement technique (experimental group)

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Figure 7: Furcation defect probing during re-entry surgery (experimental group)

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Periodontal dressings were given at a surgical site to cover the surgical areas. An antibiotic regimen of amoxicillin 500 mg thrice a day for 7 days and Nimesulide 100 mg twice daily for 5 days were prescribed. The patients were advised to rinse with 10 ml aqueous 0.2% solution of chlorhexidine gluconate for 1 minute twice a day and routine post-surgical instructions were given. After 1 week, the sutures and dressings were removed. Recall visits were carried out once every two weeks for 1 month following surgery and once every four weeks for the next two months. At these visits, oral hygiene instructions were reinforced and the areas were gently debrided.

At 6 months post - surgery, the soft tissue parameters were recorded in the same manner as before. The mucoperiosteal flaps were then reflected to repeat the hard tissue measurements. Flaps were then replaced and sutured, and antibiotics were prescribed for a period of 7 days and oral analgesics as needed. Statistical analysis was done on 'MSTAT' statistical analysis software. Significance of changes were tested by paired 't' test and changes among the groups were tested-by unpaired 't' test. Values are represented in Mean ± Standard deviation (SD).


   Results Top


At baseline, the mean PAL was 5.50 mm ± 0.80 for control group, and 5.33 mm ± 0.49 for experimental group [Table 1]. After 6 months of treatment, the mean values were 4.67 mm ± 0.78 and 3.17 mm ± 0.39 for control group and experimental group respectively. On comparing the pre-treatment values with post-treatment values, the gain in PAL were found to be statistically significant in both control ('P ' < 0.01) and experimental group ('P' < 0.001). On comparing both the groups, the mean gain in PAL was higher and also statistically significant in experimental group ('P ' < 0.001) [Table 2] and [Graph 1].
Table 2: Comparison of mean gain in PAL in mm after 6 months of treatment in the control and experimental groups

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At baseline, the mean gingival index (GI) score was 1.67 ± 0.49 for the control group, and 1.58 ± 0.33 for the experimental group [Table 1]. After 6 months of treatment, the mean values were 0.92 ± 0.33 for control group and 0.75 ± 0.30 for experimental group. On comparing the pre-treatment values with post-treatment values, the differences were found to be statistically significant for both groups ('P ' < 0.001). On comparing both groups the mean decrease in GI score was not found to be significant ('P ' = 0.35) [Table 3].
Table 3: Comparison of mean change in gingival index score after 6 months of treatment

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At baseline, the mean vertical bone level was 6.67 mm ± 0.78 for control group and 7.83 mm ± 1.11 for experimental group [Table 1]. After 6 months of treatment, the mean values were increased to 7.83 mm ± 6.72 for control group, while decreased to 6.17 mm ± 1.40 for experimental group. Control group showed significant ('P ' <0.001), mean loss of vertical bone level of 1.17 mm ± 0.39, while experimental group showed significant ('P ' <0.001) mean gain of vertical level of 1.67 mm + 0.49 [Table 4].
Table 4: Comparison of mean change of vertical bone level of furcation defect after 6 months of treatment

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At baseline, the mean horizontal bone level was 3.00 mm ± 0.00 for control group and 3.33 mm ± 0.78 for experimental group [Table 1]. After 6 months of treatment, the mean values were reduced to 2.67 mm ± 0.49 and 1.83 ± 0.72 mm for control and experimental group respectively. Control group showed significant ('P ' < 0.05) mean defect fill of 0.33 mm ± 0.52, while experimental group showed significant ('P ' < 0.001) mean defect fill of 1.50 mm ± 0.55 [Table 5] and [Graph 2].
Table 5: Comparison of mean change of horizontal bone level of furcation defect after 6 months of treatment in the control and experimental groups

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   Discussion Top


The present study showed significant gain in PAL and defect fill with the use of periosteal membrane as a barrier. These findings can be compared to observations made by Kwan et al. and Lekovic et al., utilizing periosteal graft as a barrier membrane in vertical and furcation defects, respectively. However, comparisons between the studies are difficult to make because of a number of differences in the study design. The measurements taken in this study were limited to the depth of furcation defects, and changes in the alveolar crest were not considered.

Hirata et al., described the ability of vascularized periosteum to form new bone. [12] Periosteum contains two distinct layers: A thick, outer fibrous layer and a thin inner cambium layer which is adjacent to bone. The cambium layer has the potential to stimulate the bone formation. [13] Hence, in the present study, the autogenous periosteal membrane was mobilized and placed over the exposed furcation so that the cambium layer is juxtaposed to the exposed furcation. In the present study, autogenous periosteal membrane maintained its vascular supply by the fact that it was attached at one side to the mucoperiosteal flap. This is important for the healing and maintenance of the vital cambium layer which has the potential to stimulate bone formation.

Coronally positioned flaps may have the advantage of using the periosteum as a barrier membrane. [14],[15],[16] However, in the pocket area, the periosteum may get infected and destroyed. Hence, if the pocket depth is 5 mm or more in the furcation area, then the flap cannot be coronally positioned to full extent. Hence in the present study, periosteum displacement technique was used. The principles of GTR are now the basis for most regenerative procedures. However, ideal GTR material should be economic, biocompatible, easy to harvest and manipulate. This barrier membrane is easy to harvest and manipulate and there is no need of a 2 nd surgery to remove it as well as the need for surgery to harvest the graft, causing trauma, is avoided. Also, it being a pedicle autograft, vascular supply is maintained. Thus, the autogenous vascularized periosteal membrane is an effective alternative to the existing barrier membranes.


   Conclusion Top


The results of this study indicate that periosteal membranes were effective in the treatment of human mandibular buccal grade II furcation defects. However, the clinical evidence of newly formed bone does not necessarily indicate the presence of new attachment (new cementum and new functional periodontal ligament). Histologic evaluation is needed to confirm the efficacy of periosteal membrane in promoting true periodontal regeneration. The future of regenerative therapy is indeed optimistic, due to the ongoing refinement of the variables in existing techniques, and also the utilization of new technology.

 
   References Top

1.Jepsen S, Eberhard J, Herrera D, Needleman I. A systematic review of guided tissue regeneration of periodontal furcation defects: What is the effect of guided tissue regeneration compared with surgical debridement in the treatment of furcation defects? J Clin Periodontol 2002;29:103-16.  Back to cited text no. 1
    
2.Fell HB. The osteogenic capacity in vitro of periosteum and endosteum isolated from the limb skeleton of fowl embryos and young chicks. J Anat 1932;66:157-80.  Back to cited text no. 2
    
3.Cohen J, Lacroix P. Bone and cartilage formation by periosteum: Assay of experimental autogenous grafts. J Bone Joint Surg Am 1955;37:717-30.  Back to cited text no. 3
    
4.Raphaël B, Morand B, Bettega G, Lesne C, Lesne V. Alveolar and hard palate repair by tibial periosteal graft in complete unilateral cleft lip and palate: Long-term follow-up of 51 cases. Ann Chir Plast Esthet 2002;47:196-203.  Back to cited text no. 4
    
5.Lekovic V, Kenney EB, Carranza FA, Martignoni M. The use of autogenous periosteal grafts as barriers for the treatment of class-II furcation involvements in lower molars. J Periodontol 1991;62:775-80.  Back to cited text no. 5
    
6.Kwan SK, Lekovic V, Camargo PM, Klokkevold PR, Kenney EB, Nedic M, et al. The use of autogenous periosteal grafts as Barriers for the treatment of intrabony defects in humans. J Periodontol 1998;69:1203-9.  Back to cited text no. 6
    
7.Wada K, Mizuno H, Hata K, Ueda M. A novel approach to regenerating periodontal tissue using cultured periosteum. The 8 th International Symposium on Periodontics and Restorative Dentistry; Poster No. 11.  Back to cited text no. 7
    
8.Tobon-Arroyave SI, Dominguez-Mejia JS, Florez-Moreno GA. Periosteal grafts as barriers in periradicular surgery: Report of two cases. Int Endod J 2004;37:632-64.  Back to cited text no. 8
    
9.Gaggl A, Jamnig D, Triaca A, Chiari FM. A new technique of periosteoplasty for covering recessions: Preliminary report and first clinical results. Perio 2005;2:55-62.  Back to cited text no. 9
    
10.Lekovic V, Kenney EB, Kovaeevic K, Carranza FA Jr. Evaluation of guided tissue regeneration in class II furcation defects: A clinical re-entry study. J Periodontol 1989;60:694-8.  Back to cited text no. 10
    
11.Loe H, Silness J. Periodontal disease in pregnancy: I: Prevalence and severity. Acta Odontol Scand 1963;21:533-51.  Back to cited text no. 11
    
12.Hirata A, Maruyama Y, Onishi K,Hayashi A, Saze M, Okada E. A vascularized artificial bone graft using the periosteal flap and porous hydroxyapatite: Basic research and preliminary clinical application. Wound Repair Regeneration 2004;12:1067-1927.  Back to cited text no. 12
    
13.Ito Y, Fitzsimmons JS, Sanyal A, Mello MA, Mukherjee N, O'Driscoll SW. Localization of chondrcyte precursors in periosteum. Osteoarthritis Cartilage 2001;9:215-23.  Back to cited text no. 13
    
14.Gantes B, Martin M, Garrett S, Egelberg J. Treatment of periodontal furcation defects: (II) Bone regeneration in mandibular class II defects. J Clin Periodontol 1988;15:232-9.  Back to cited text no. 14
    
15.Garrett S, Martin M, Egelberg J. Treatment of periodontal furcation defects. Coronally positioned flaps versus duramater membranes in class II defects. J Clin Periodontol 1990;17:179-85.  Back to cited text no. 15
    
16.Kerdvongbundit V, Sirirat M, Sirikulsathean A. A clinical comparison of the new attachment obtained by guided tissue regeneration and coronally positioned flap techniques in the management of human molar furcation defects. Aust Dent J 1999;44:31-9.  Back to cited text no. 16
    

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Correspondence Address:
Vikas Verma
Department of Periodontics, Teerthanker Mahaveer Dental College and Research Center, Moradabad
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.90280

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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