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Allogenic tissue, such as demineralized

freeze-dried bone allograft (DFDBA), can also

be used in combination with CS as a bone-

filling binder.15,16 A CS or synthetic mem-

brane barrier is then added to prevent

ingrowth of cells. Nonresorbable synthetic

membranes, such as expanded polytetraflu-

oroethylene, are far more invasive and time-

consuming than is a resorbable CS mem-

brane.17 Calcium sulfate, a material that has

been used as a bone-filling material for

more than 110 years,18 has been shown to

be completely bioabsorbable,19 to be os-

teoconductive,14 to allow fibroblast migra-

tion,20 to not cause an inflammatory re-

sponse,21 and to not elevate serum calcium

levels.22 Recently, it has been shown that CS

can be manufactured into a granular

composite of CS and poly-L-lactic acid to

decrease the degradation rate if the appli-

cation calls for a slower dissolution.23

Strocchi et al observed significantly more

blood vessel growth in defects filled with

CS than those filled with autograft, proving

its angiogenic properties.24

Blood vesselsprovide nutrition for growing bone and

accelerate bone growth. Two parallel series

of mechanisms are triggered by the degra-

dation of CS into deep bone defect

(Figure 1). The first mechanism involves

the release of calcium and sulfur ions in

the biological environment, which results in

carbonate apatite formation and calcium

ion stimulation of cellular activity.25 The

second mechanism is the precipitation of

calcium phosphate, which leads to a

transient, local drop in pH. This causes

surface demineralization of existing bone

resulting in exposure of bioactive molecules

and the release of growth factors such as

transforming growth factors and bone

morphogenetic proteins, which stimulates

the growth of bone in defects filled with

CS.2528 Calcium sulfate has been used as a

bone graft by itself, in combination with

other bone grafts, and also as a barrier to

treat extraction sockets.

CASE REPORT

A 37-year-old male patient presented with

advanced periodontal disease around an

upper canine. A deep bone defect of 8 mm

was found in the distal aspect of the tooth,

as seen grossly and by radiograph in

Figure 2a and b.

The deep bone defect was accessed by

elevating the full mucoperiosteal plate. The

defect was debrided of all granulation tissue,

and the root surface was carefully planed.

DFDBA was mixed with medical grade CS

(trade name DentoGen, Orthogen, LLC,

Springfield, NJ) at a ratio of 75:25 (DFDBA:

DentoGen; Figure 3a). Fast-setting solution

was added to this mixture to form the bone

graft composite. The composite was grafted

into the deep bone defect using a spatula, as

shown in Figure 3b. It was tightly compressed

to thoroughly fill the defect. The defect was

closed with a pure CS (DentoGen) barrier to

prevent the ingrowth of soft tissue. Fast-setting solution was added to CS to form the

putty, which was implanted as a barrier

(Figure 3c). Nonresorbable suture was placed

to reposition the flap (Figure 3d). Preopera-

tive digital radiographs of the deep bone

defect were taken to facilitate comparison

with future time points. Digital radiographs of

the grafted site were taken at 1- and 5-month

FIGURE 1. Calcium sulfate degradation mechanismin a deep bone defect.

Bone Repair in Periodontal Defect

288 Vol. XXXVII/No. Two/2011


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postoperative time points. A standard bite

holder was placed while taking a radiograph.

The patient was followed every month for up

to 6 months.

When observed grossly, the site was

healing well at the 1-month time point,

and radiographs showed the grafted mate-

rial was slowly resorbing (Figure 4a). At the

5-month postoperative time point, the site

was grossly observed to have healed well,

and the deep bone defect observed in the

preoperative radiograph was now replaced

with bone, as evidenced by radiographs

(Figure 4b).

FIGURE 3. (a) Mixture of allograft and DentoGen. (b) Allograft and DentoGen composite implanted inperiodontal deep bone defect. (c) Defect closed with DentoGen membrane barrier. (d) Sutures placedover the top.

FIGURE 2. (a) Preoperative periodontal deep bone defect around upper canine. (b) Preoperativeradiograph of periodontal deep bone defect around upper canine.

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DISCUSSION

A severe form of periodontal disease has

been surgically treated using a 75% DFDBA/

25% CS composite graft and a pure CS

membrane barrier. Because CS has signifi-

cant bone regeneration properties of its own

as a bone graft, it not only acts as a binder

that prevents DFDBA from migrating out of

the deep bone defect but also further aids in

bone growth by depositing a calcium

phosphate trellis, preventing ingrowth of

soft tissues, stimulating blood vessel forma-

tion, and affecting the release of growth

factors.

When comparing the gross initial bonedefect to the 5-month time point, a com-

plete healing of the bone with no gingival

recession was noted. At both the 1- and 5-

month time points, the patient showed no

signs of discomfort, and no infection was

observed. Analysis of the radiographs veri-

fied the gross observations as the bone

showed signs of remodeling at the 1-month

time point and complete bone growth at the

5-month time point. As DFDBA underwent

remodeling, CS degraded and slowly re-

sorbed, leading to the formation of a calcium

phosphate trellis, which further stimulatedbone growth. This resulted in the deep bone

defects being filled with regenerated bone

at the 5-month postoperative time point.

These results were similar to previous

clinical studies on 19 patients with chronic

periodontitis, which indicate that CS, used as

a binder and barrier in combination with

DFDBA, supports significant clinical improve-

ment in intrabony defects.29 The authors

observed that after 6 months, there was areduction in probe depth, gains in clinical

attachment level, and defect fill and resolu-

tion. A similar study by Harris and colleagues

evaluated a CS porous hydroxyapatite and

tetracycline binder combined with DFDBA

and a CS barrier in 100 patients.30 Their

technique also found a decrease in probe

depth and an increase in clinical attachment

FIGURE 4. (a) Radiograph obtained 1 month postoperatively. (b) Radiograph obtained after 5 monthsshows degradation of grafted material and bone growth in the original defect.




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level after 6 months. A long-term, 6-year

study of 12 patients by Orsini et al also

yielded similar results.31 They used a combi-

nation of autogenous bone grafting plus CS

as a binder and barrier and compared it to a

defect treated with a bioabsorbable mem-

brane.31 After 6 years, there was no signifi-

cant difference found between the two

techniques. There was also a decrease in

probe depth and an increase in clinical

attachment level. It was also observed that

there was no statistically significant differ-

ence when comparing the long-term, 6-year

results to their short-term, 6-month data.

CONCLUSION

In this surgical case report, medical-grade CS

mixed with DFDBA was found to be a

biocompatible composite graft with the

ability to provide radiographic evidence of

hard-tissue repair of a periodontal intrabony

defect. The incorporation of CS improves the

handling characteristics of DFDBA as well as

the cost-effectiveness of the procedure.

ABBREVIATIONS

CS: calcium sulfate

DFDBA: demineralized freeze-dried bone

allograft

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