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Table of Contents   
ORIGINAL RESEARCH  
Year : 2014  |  Volume : 25  |  Issue : 5  |  Page : 589-593
The effect of Emdogain gel on periodontal regeneration in autogenous transplanted dog's teeth


1 Department of Dentistry, University of Coimbra, Portugal
2 Department of Biophysics and Biomathematics, University of Coimbra, Portugal
3 Department of Pathologic Anatomy, Faculty of Medicine, University of Coimbra, Portugal

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Date of Submission15-Dec-2012
Date of Decision23-Nov-2013
Date of Acceptance28-May-2014
Date of Web Publication16-Dec-2014
 

   Abstract 

Aim: The aim of this study was to assess the enamel matrix derivative (EMD) as biomaterial used in autogenous tooth transplantation.
Material and Methods: The study consisted of 3 beagle dogs, 5 months old, in which six incisors and six premolars were transplanted to mechanically prepared recipient alveolar sockets. One group of teeth was transplanted to a recipient bed, with EMD in the root surface. The second groups of teeth were transplanted using saline solution in the root surface. Every week, clinical examinations were done. Nine weeks later, the animals were killed and the specimens decalcified and prepared for histological and imunohistochemical analysis. Periodontal healing was evaluated by undertaking histomorphometric investigation and analyzed using the Mann- Whitney test (P = 0.05).
Results: In both groups, all the transplanted teeth survived. Between the experimental groups, there was statistically significant difference in the complete healing (P = 0.004). There was statistically significant difference between the treatment group in the occurrence of inflammatory root resorption (P = 0.015) and the occurrence of replacement root resorption (P = 0.041).
Conclusions: Emdogain gel used on the surface of transplanted teeth improves the occurrence of complete healing and reduces root resorption.

Keywords: Autogenous tooth transplantation, beagle dogs, Emdogain gel, periodontal regeneration

How to cite this article:
Ferreira MM, Filomena BM, Lina C, Barbara O, Palmeirao CV. The effect of Emdogain gel on periodontal regeneration in autogenous transplanted dog's teeth. Indian J Dent Res 2014;25:589-93

How to cite this URL:
Ferreira MM, Filomena BM, Lina C, Barbara O, Palmeirao CV. The effect of Emdogain gel on periodontal regeneration in autogenous transplanted dog's teeth. Indian J Dent Res [serial online] 2014 [cited 2019 Oct 22];25:589-93. Available from: http://www.ijdr.in/text.asp?2014/25/5/589/147099
Autogenous tooth transplantation could be an option to restore the arch if there is an existing suitable donor tooth. [1],[2] A successful result of tooth transplantation depends upon the optimal and incident-free healing of the periodontium. [3],[4] The success depends on the vitality of remaining periodontal ligament (PDL) cells in the donor root, the shape and the site of the recipient socket as well the vascularity of the recipient bed. [5],[6],[7],[8] In addition, immature teeth, with an open apex are better for transplantation than fully mature teeth. [4] In order to ameliorate nutrition and maintain cell activity in these tissues, several authors recommend that teeth should be transplanted to the socket with regenerative tissues. [6],[7],[9],[10] This surgical method may recover the circulation and innervations of the original pulp tissue, and dentin development continues after transplantation of immature teeth.

Healing and regeneration of any type of tissue requires multifactor interaction between different phenotypes of cells, growth factors, hormones, and the extracellular matrix proteins within which these events occur. Enamel matrix derivative (EMD), is extracted from developing porcine tooth germs and has been frequently used as an effective material to regenerate periodontal tissues. [11] Several clinical studies reported that EMD used for intrabony periodontal defects leads to regeneration of the periodontal ligament, enhances clinical attachment and alveolar bone growth successfully and promotes cementum formation in periodontal tissue. [12],[13],[14],[15] However, for its use in transplanted teeth, there are limited investigations to evaluate the healing process that occurs and how enamel matrix proteins promote wound healing and help tissue regeneration.

The aims of the current study were to assess the therapeutic effect of Emdogain (Biora, Malmo, Sweden), an EMD mainly composed of enamel matrix proteins (test), used on the root surface on the transplanted teeth, in dogs, via an experimental study, analyzing various patterns of root resorption in transplanted teeth to a recipient bed.


   Materials and methods Top


A total of 3 beagles of 5 months old and an average weight of 11.73 ± 1.13 kg were acquired from the University of Córdova - Spain.

Before the start of the experiment, application was made to the Institutional Animal Care and Use Committee of The Portuguese Veterinary Directory Board, approval number 002194. The animal experimental procedures were performed in the National Zootechnical Station - Institute for Biomedical Technology, Santarém, Portugal, in accordance with the International Guiding Principles for Animal Research.

Six noncarious and periodontally sound incisors and six noncarious and periodontally sound premolars (PM) from 3 male beagles were selected. All the experimental procedures were performed with the animals under general anesthesia, using preanesthetic sedation with 0.05 mg/kg of body weight of acepromazine (Calmivet ® , Vetoquinol, Lure, France) administered intramuscularly, and anesthetic induction with 10 mg/kg of body weight of thiopental (Pentotal ® , Queluz de Baixo, Portugal) - administered intravenously. After intubation the anesthesia was maintained with a mixture of oxygen and 1-2% of isoflurane (Isoflo, Veterinaria Esteve, Barcelona, Spain). Throughout the duration of general anesthesia, the dogs received normal saline solution intravenously, and no additional infiltrative anesthesia was performed.

All selected teeth, incisors (I), (n = 6) and PM, (n = 6) were extracted as atraumatically as possible, under aseptic conditions. The alveolus at each site was enlarged with a bur Ψ 3,5 to receive the incisors and Ψ 4,2 to receive the PM (Strauman- Basel- 4052, Switzerland), under copious irrigation with normal saline solution. The lower I1 was transplanted to the upper I1 site and the lower PM1 was transplanted to the lower I1 site.

The roots and sockets were gently rinsed with 5 mL each of normal saline solution immediately before the following treatment protocols.

  • Group A (n = 6): The teeth were transplanted to the recipient beds after covering the root with Emdogain.
  • Group B (n = 6): The teeth were transplanted to a recipient bed after covering the root with saline solution.
  • Group C (n = 3): Negative control. No treatment was performed on the teeth.


After transplantation the teeth were splinted with vycril 3/0. [9],[10],[15] The animals were given standard food softened with hot water. Immediately after transplantation and for 5 subsequent days, the animals were given enrofloxacine (5 mg/kg of body weight), to prevent postoperative infection. In addition, for possible postsurgical pain, each animal was given 0.01 mg/kg of body weight of buprenorphine once daily.

The dogs received daily plaque control and chlorhexidine gluconate irrigation until they were sacrificed. The animals were euthanized 63 days after transplantation. The dogs were deeply anesthetized with an overdose of intravenous pentobarbital at 100 mg/kg of body weight. After the dissection of the carotid vein, perfusion was performed with 40 ml of 4% paraformaldehyde in phosphate buffer (pH - 7.4). Jaw blocks containing the transplanted teeth were resected and fixed in the same fixative at 4°C for 2 days. They were then transferred to 50% formic acid and 20% sodium citrate for demineralization for 2 months and embedded in paraffin. The paraffin embedded blocks were subsequently longitudinally cut in a buccolingual direction at a thickness of 5 μm, corresponding to the root canal. The section that was technically the best was stained with hematoxylin and eosin. [9],[16] After deparaffinization and digestion in protease solution, the specimens were immunostained by the streptadin-biotin complex method for immunohistochemistry for keratin MNF116. [17]

Histomorphometric evaluation

Histomorphometric analysis was performed with the aid of the software ImageJ 1.30 (Image Processing and Analysis in Java - National Institute of Mental Health, Bethesda, Maryland, USA) at ×40 magnification. [9] Histological features of the root surfaces and healing of the periodontal connective tissues were assessed and compared in the test and control samples. The analysis of the periodontal morphology was carried out according to the criteria established and classified as follows: percentage of complete healing; Percentage of superficial root resorption; percentage of inflammatory root resorption; percentage of replacement root resorption. [9]

Statistical analysis

For statistical analysis the differences among the groups were compared by using the Mann-Whitney test. The significance level was set at 5%. All statistical analysis was performed using statistics software (SPSS version 1.4, Japan Inc., Tokyo, Japan).


   Results Top


All animals survived and tolerated all operative procedures well, their behavior did not change and no teeth were lost. In Group C, the PDL was rich in collagen fibers and fibroblast. The dentin was covered by cementum and the alveolar walls were rich in osteoblasts and osteocyts [Figure 1]. In the histological observations at 9 weeks after transplantation (Groups A and B), the space of the PDL was reestablished and we could see by MNF116 the epithelial cells of Malassez [Figure 2]. Histological features of tissue attachment to the root surfaces, proliferative capacity of periodontal connective tissues and orientation of collagen fibers were observed [Figure 3].
Figure 1: Histological photograph of the control teeth root surface with PDL rich in collagen fibers and fibroblast and dentin covered by cementum and the alveolar walls rich in osteoblasts and osteocyts (Dog3, teeth 3.2- Group C). (HE ×40)

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Figure 2: Histological photograph of the experimental teeth root surface, 9 weeks after transplantation, with space of the periodontal ligament reestablished and with epithelial cells of Malassez (Dog2, teeth 21- Group A). (MNF116 ×200)

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Figure 3: Histological photograph features of the experimental root surface with periodontal connective tissues and orientation of collagen fibers (Dog 1, teeth 21- Group A). (HE ×40)

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In teeth transplanted with EMD (Group A), the mean occurrence of complete healing was 98.4%, and in the saline solution (Group B) was 81.1%, with statistically significant difference (P = 0.004) [Table 1]. The mean occurrence of replacement resorption in Group A (1.5%), compared with Group B (11.4%), had statistically significant difference (P = 0.04) [Table 1]. The mean occurrence of superficial root resorption was high in Group A (7.1%), compared with Group B (4.9%), but there was no significant difference (P = 0.81) [Table 1]. In roots with inflammatory root resorption, numerous odontoclasts were observed [Figure 4]. The mean occurrence of inflammatory root resorption was higher in the Group B, saline solution (7.4%), than with Emdogain (Group A) (0%), with statistically significant difference (P = 0.015) [Table 1].
Table 1: Periodontal healing pattern for different groups and statistical comparison by using the Mann-Whitney test (P=0.05)


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Figure 4: Histological photograph of the experimental root surface with inflammatory root resorption, and numerous odontoclasts. (Dog 2, teeth 12- Group B). (HE ×40)

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   Discussion Top


Teeth transplantation is a technique which can be used as an alternative in treating premature loss of teeth and should be based on critical case selection. Even though, autotransplantation is not commonly used, it can be an alternative to dental implants in some patients in whom dental implants become impossible due to inadequate bone support and patients in growing stages. [1],[2],[3],[4],[17],[18],[19],[20] Even though, PDL has demonstrated a remarkable capacity for repair and regeneration, troubles in these biological processes may be considered as the main cause of failure of transplanted teeth. Although, tooth autotransplantation is a very useful method for replacing missing teeth, further approaches for enhancing the results are highly desirable.

Several studies of tooth transplantation have been based on animal models in monkeys, rats and dogs. [5],[6],[9],[21],[22] In this study, we aimed to investigate the pattern of periodontal healing process in an in vivo dog model, using EMD on root surface to compare it with saline solution.

Hamamoto et al., [23] have demonstrated by immunohistochemistry that in rat molars transplanted to the abdominal wall, EMD is accumulated in the cells at the root surface and promotes regeneration of the periodontal tissues during early wound healing.

In our study, the recipient bed is surgically prepared in the jaw bone and the teeth are transplanted in the same surgical intervention after using EMD or saline solution on the root surface. The results of this study revealed same pattern of bone healing in the test and control group.

Our observations and findings demonstrated that the periodontal tissues have a remarkable capacity for repair and all transplanted teeth had a similar progression of regeneration. In addition, the osteoblast-like cells lining the newly formed alveolar bone, suggest that osteogenic cells in PDL might proliferate and differentiate into osteoblast-like cells. In addition, in this study, active PDL adhering to the alveolar bone wall and to the root of the tooth, which facilitates reinsertion of collagen fibers onto the cementum surface, was seen.

The major cause of loss of reimplanted and transplanted teeth is the induction of external root resorption, due to the remnants of necrotic PDL on the cementum side. [9],[10]

It was demonstrated in this study that the mean occurrence of replacement resorption was high in teeth transplanted with saline solution (11.4%), compared with teeth transplanted to a recipient bed in which Emdogain is used (1.5%), with statistically significant difference (P = 0.04). In addition all teeth presented a similar tendency towards the occurrence of superficial root resorption with 7.1% in Group A, compared with 4.9% in Group B, without statistically significant difference (P = 0.81). Complete healing is superior in the Emdogain group (98.4%), compared with saline solution group (81.1%), with statistically significant difference (P = 0.004).

The mean occurrence of inflammatory resorption was high in teeth transplanted using saline solution (7.4%), compared with teeth transplanted to a recipient bed in which Emdogain was used (0%), with statistically significant difference (P = 0.015).

This may be explained by the fact that Emdogain, have the activity of growth factors including transforming growth factor and bone morphogenetic proteins, [24] the increased phagocytic activity of monocytic cells, [25] and the inhibition of tumor necrosis factor [26] that support the biological significance of EMD for wound healing and periodontal regeneration.


   Conclusion Top


This experimental study demonstrated that there were no differences in the complete periodontal healing process between the material used in transplanted teeth. Our results also indicate that PDL tissue contains osteoprogenitor cells that have the ability to participate in alveolar bone regeneration.

The results of this study suggest that EMD might create a favorable environment, reducing replacement and inflammatory root resorption and promoting wound healing, and deserve attention as a new tool for tooth autotransplantation, but further investigations should focus on the optimization of protocols as the extra-oral time and other factors that need to be well-controlled.

 
   References Top

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Correspondence Address:
Manuel Marques Ferreira
Department of Dentistry, University of Coimbra, Portugal

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.147099

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