Clinical Evaluation of Freeze-dried Bone Allografts in Periodontal Osseous
Animal experimentation has shown that freeze-dried bone is replaced by host b o n e , is mechanically competent, and is nonantigenic. It serves as a template or inducer of new bone formation, and can serve as an acceptable substitute for autogenous bone in the repair of artificially-created defects. Studies have suggested that cortical bone may be superior to cancellous bone when used as a freeze-dried graft in osseous defects. Clinically, freeze-dried bone allografts have been implanted successfully by surgeons to treat fractures, to fill bone cysts, and to reconstruct limbs after tumor resection. In addition, freeze-dried bone allografts have been used successfully by dentists to treat tumors of the j a w , to facilitate bone formation after surgical repositioning of impacted adult cuspids, to induce bone repair of periapical defects, to restore deficient alveolar ridges prior to fashioning intraoral protheses, and to reconstruct mandibular contour. 18-20
21
22,23
24
25,
Defects*, †
20,
by
2 6
2 7
28-32
JAMES T . M E L L O N I G , A.B., D.D.S.,
33-35
M.SC. ‡
36, 3 7
38
G E R A L D M . B O W E R S , B.S., D . D . S . , M . S . § R O B E R T W . BRIGHT, M . D . | |
39
40
When the literature was reviewed, in only one report was freeze-dried bone used in periodontal defects. In this report, Hurt used dogs as his experimental model and created artificial two-wall bony defects about the maxillary cuspids. Half of the defects were treated by subgingival curettage, while the other half were packed with freeze-dried allograft bone. Clinically, there were no noticeable differences when the control and experimental sides were examined. However, histologically there was convincing evidence that the freeze-dried bone promoted osseous obliteration of the defects. Hurt suggests that freeze-dried bone may have some potential in periodontal therapy. A study is in progress to determine if this is, in fact, true. This paper reports the current findings from a longitudinal study using freeze-dried crushed cortical bone as a graft material in human periodontal defects.
JOSEPH J . L A W R E N C E , D.D.S., M . S . H
41
R E F O R M A T I O N O F L O S T alveolar bone and restoration of a
functional attachment apparatus is the primary goal of periodontal osseous grafting procedures. T o achieve this goal, a wide variety of grafting materials has been employed. Autogenous bone appears to offer the greatest degree of success, but this material has certain limitations. The clinician faces the problem of obtaining sufficient quantities of autogenous bone from the intra-oral donor sites for utilization in large or multiple defects, and while autogenous marrow is readily available in sufficient quantity from the iliac crest, previous studies have shown that it may induce resorption when used in a fresh state. Furthermore, the utilization of this material in the fresh or frozen state requires an additional surgical incision which results in an additional postoperative morbidity for the patient. 1-6
7-10
11
12
13-15
MATERIALS AND METHODS
The freeze-dried bone used in this investigation had been obtained from the Navy Tissue Bank, Naval Medical Research Institute, Bethesda, Maryland. The bone was procured from a sterile autopsy which had been performed within 24 hours after death. Cortical bone was removed from the tibia, fibula, or femur, was cut into strips, and cultured for bacterial contamination. It was frozen in a liquid nitrogen freezer ( - 1 9 7 ° C ) and stored at this temperature until placed in a commercial freezedrying chamber, where at least 95% of the total water content was removed under vacuum. The freeze-dried bone was ground under sterile conditions to a powderlike consistency of 100 to 300 in a Tekmar Analytical M i l l , * and placed in 1/2-oz glass bottles, which were sealed (Fig. 1) and subjected to a secondary vacuum. The bone deposit could then be safely stored at room temperature until used. The vacuum was tested periodically to insure that the seal had not been lost.
The use of freeze-dried crushed cortical bone allograft may offer a solution to some of these problems. This material is obtained under sterile conditions from a cadaver which has met the rigid criteria for tissue donation established by the Navy Tissue Bank. The bone is frozen and the tissue water is removed by the process of lyophilization. This process is commonly referred to as freeze-drying and is carried out under vacuum at low temperature ( - 4 0 ° C ) . 16,
1 7
* This project was supported by Bureau of Medicine and Surgery, Navy Department, under MR041.20.02.6053A3ID and Naval Medical Research Institute Research task M4318.01.0002BGJ2. †The opinions or assertions contained herein are the private ones of the writers and are not to be construed as official or as reflecting the views of the Navy Department or the naval service at large. ‡Periodontics Section, U.S. Naval Station, Box 12, FPO New York 09551. § University of Maryland School of Dentistry, Baltimore, Maryland 21201. || Present address, Orthopedic Department, University of Florida, Gainesville, Florida 32601. 1 Periodontics Department, Naval Graduate Dental School, National Naval Medical Center, Bethesda, Md. 20014.
* Tekmar Analytical Mill, Model A-10 Tekmar Company, P.O. Box 37202, Cincinnati, Ohio 45222. 125
J. Periodontol. March, 1976
I E 3 Mellonig, Bowers, Bright, Lawrence
The collaborators were asked to reenter the graft site in 1 year and to record the amount of osseous regeneration, or lack thereof. This was to be accomplished by comparing preoperative measurements, radiographs, and photographs with similar data obtained at the time of reentry. The large number of investigators in this study precluded the use of specific millimeter measurements as the method of assessing osseous regeneration and pocket elimination. Consequently, the collaborators were permitted to measure the depth and width of defects by any method with which they were familiar. Some utilized standardized periodontal probes; others combined probing with measurements obtained with silver points or Hirschfeld points. Still other clinicians utilized threedimensional drawings plus measurements to estimate the FIGURE 1. Freeze-dried bone allograft, particle size 100 to 300 amount of osseous regeneration. In all cases, the cliniµ. The material may be stored indefinitely in this container at cians were asked to correlate the pre- and postoperative room temperature until used. measurements, radiographs, and photographs, and to estimate and record the amount of bony regeneration and pocket elimination as either complete, greater than 50%, Forty-four periodontists from military and civilian less than 50%, or none. It was felt that it was well within practices were selected to clinically evaluate the efficacy the capability of every periodontist in this study to make of freeze-dried bone in periodontal osseous defects. A l l a reasonably accurate determination of the amount of collaborators were asked to use the material in patients osseous regeneration using the aforementioned criteria. with one-wall, two-wall, widemouthed three-wall, and combination defects, as well as furcation involvements. The data obtained by the clinicians were then submitNarrow three-wall defects were excluded from this study, ted to the tissue bank, where they were compiled and since experience has shown that this defect will often tabulated by the authors. O f the 44 investigators, 37 had repair without a graft material being used. completed cases and submitted data at the time of Each patient selected for the study was required to sign an informed consent authorization form before receiving the human allograft tissue. This form stated that a graft was "obtained from another human body; that the tissue was procured, processed, and preserved in accordance with established medical procedures; that the graft was believed to be free from bacterial contamination; that the success of the transplant was not guaranteed; and that therapy was planned as a two stage procedure with the second operation to occur 1 year postgrafting to allow for evaluation and additional therapy as needed." Procedures to be accomplished preliminary to implantation of the allograft included: demonstration of effective plaque control by the patient, scaling and prophylaxis, and an adjustment of the occlusion, if indicated. Preoperative and postoperative radiographs were required and were supplemented by intraoral Kodachrome pictures prior to surgery, at the time of surgery, and at the 1-year reentry. In addition, each collaborator provided narrative summaries of the patient's general medical status, and sequential evaluations of the graft at the time of follow-up visits. The clinician was given the option of flap design, periodontal dressings, and specific antibiotic regimen. He also had the choice of whether to perform root planing and to accomplish intramarrow penetration, and whether to "fill" or "overfill" the defect. A t the completion of surgery, each clinician was required to complete the data form indicating specifically how he had managed the treatment of the patient with regard to the foregoing parameters.
submission of this report. RESULTS
Over 300 osseous defects in 189 periodontal patients have been treated with freeze-dried crushed cortical bone allografts. T o date, a total of 97 defects have been reentered in 48 patients. The patients ranged in age from 23 to 63, with a mean age of 45.9 years. There were 36 men and 12 women. Full-thickness flaps, root planing, and intramarrow penetration were employed in most cases (Table 1). The majority of clinicians stated that they "overfilled" the defect with allograft. Wound approximation was accomplished in 88 defects, but complete coverage could not be obtained in nine instances. In all cases, postoperative healing was considered normal and there were no reported clinical signs of immunologic rejection. A variety of periodontal dressings was employed, and in 7 instances dressings were not utilized. Erythromycin was the antibiotic most frequently given to the patient. There were no reports of postoperative sequestration of the graft material. Radiographically, there appeared to be complete incorporation of the graft, except that in one case it could be delineated from the surrounding bone. Root resorption and ankylosis were not observed. The amount of osseous regeneration as determined by pre- and postoperative radiographs, measurements, and photographs is summarized in Table 2. O f the 97 osseous defects treated with grafts, 23 were reported as complete bony regeneration, 39 had greater than 50% regenera-
Volume 47 Number 3
Freeze-dried Bone Allografts
effectiveness were never obtained. Over this 12-year period, large fragments of cancellous bone approximately 1 to 2 mm in diameter were employed. It was the opinion of many periodontists who used the material in this form that it was slowly, if ever, replaced with new host bone. Continued sequestration of rather large particles from the sulcus also presented some difficult management problems.
tion, and 23 had less than 50% regeneration. Twelve defects failed to demonstrate any bony fill. Thus, freezedried bone caused a 50%, or better, regeneration in 64% of the defects and stimulated a partial fill in another 24% of the cases. Figure 2 through 5 are photographs representative of osseous regeneration obtained with freeze-dried bone allografts in some of the reported defects shown in Table 2. Residual pocket depth appeared to be inversely proportional to the amount of regeneration of the defect. The greater the regeneration, the less was the pocket depth (Table 3). Twenty-four of the defects showed complete elimination of pocket depth; 44 showed greater than 50% reduction; and 25, less than 50% reduction. The pocket depth in four did not change.
A particle size of 100 to 300 f i was employed in this study in an attempt to overcome the problems observed with the larger bone chips. In addition, studies suggest that fine particles of bone (100 to 300 µ) are active in inducing regeneration of the alveolar process. The small particle size used in this study appears to have solved the problems previously encountered with the large fragments of freeze-dried bone. There have been no reports of sequestration around the wound site, and in only one case was incomplete resorption of the graft material reported. 4 2
43-45
DISCUSSION
Freeze-dried bone has been used successfully for over 20 years to treat a variety of orthopedic and oral surgical conditions. It has been also employed, on a limited basis,
It is noteworthy that there were no reports of postoperative infection and no mention of any clinical signs of immunologic rejection. Studies reported in the medical
in the management of osseous defects of the periodontium for over
12 years. Unfortunately, data on its
T A B L E 1. Surgical Data on 97 Defects
Flap type
Root planing
Intramarrow penetration
Wound closure
Wound healing
Full
Partial
Yes
No
Yes
No
Complete
Incomplete
Normal
Delayed
90
7
93
4
70
27
88
9
97
0
Type of dressing
(62) Professional Products (16) Coe-Pak (7) None (3) Baer-Sumner (3) Kirkland (1) Orahesive
Reentry postsurgery
Type of antibiotic
(59) Erythromycin (14) Tetracycline (12) KeHex
(61) (24) (8) (3) (1)
(5) Penicillin (4) None (3) Cleomycin
12 mo. 13 mo. 14 mo. 11 mo. 15 mo.
T A B L E 2. Osseous Regeneration Repair Defect morphology
Number of defects Complete
>50%
50% osseousperiodontal osseous defects. However, final determinaregeneration was reported. D . Preoperative radiograph. E, tion must await the outcome of a larger number of cases Fifteen-month postoperative radiograph. and also histologic evidence.
Volume 47 Number 3
Freeze-dried Bone Allografts
129
FIGURE 3. (Case submitted by R. W. Koch). A, A two-wall defect on the distal of the mandibular left first bicuspid. The facial and proximal walls remain. B, The graft material is shown in place. C, The graft site at I year reentry. Reported as > 50% osseous regeneration. D, Preoperative radiograph. E, One-year postoperative radiograph.
FIGURE 4. (Case submitted by C. Julienne). A , one-wall defect on the distal of the maxillary right second bicuspid. The proximal wall remains. B, Clinical appearance of the graft site at 13-month reentry. Reported as complete regeneration. C , Preoperative radiograph. D, Thirteen-month postoperative radiograph.
130
J. Periodontal. March, 1976
Mellonig, Bowers, Bright, Lawrence
FIGURE 5. (Case submitted by T. R. Tempel). A, A two-wall defect on the mesiolingual of the maxillary left central and a two to three-wall combination defect on the mesial, lingual, and distal of the maxillary left lateral. B, The defects are shown at time of surgery with freeze-dried bone in place. C, Appearance of graft site at I year reentry. Both defects reported as complete regeneration. D, Preoperative radiograph. E, One-year postoperative radiograph.
T A B L E 3. Pocket Elimination Defect morphology
Number of defects
Complete
Widemouthed three-wall Two-wall One-wall Combination one to two-wall Combination one to three-wall Combination two to three-wall Furcation
18 15 18 12 7 14 13
4 5 4 4 2 4 1
Total
97
Percentage
100%
>50%
Animal experimentation has shown that freeze-dried bone is replaced by host b o n e , is mechanically competent, and is nonantigenic. It serves as a template or inducer of new bone formation, and can serve as an acceptable substitute for autogenous bone in the repair of artificially-created defects. Studies have suggested that cortical bone may be superior to cancellous bone when used as a freeze-dried graft in osseous defects. Clinically, freeze-dried bone allografts have been implanted successfully by surgeons to treat fractures, to fill bone cysts, and to reconstruct limbs after tumor resection. In addition, freeze-dried bone allografts have been used successfully by dentists to treat tumors of the j a w , to facilitate bone formation after surgical repositioning of impacted adult cuspids, to induce bone repair of periapical defects, to restore deficient alveolar ridges prior to fashioning intraoral protheses, and to reconstruct mandibular contour. 18-20
21
22,23
24
25,
Defects*, †
20,
by
2 6
2 7
28-32
JAMES T . M E L L O N I G , A.B., D.D.S.,
33-35
M.SC. ‡
36, 3 7
38
G E R A L D M . B O W E R S , B.S., D . D . S . , M . S . § R O B E R T W . BRIGHT, M . D . | |
39
40
When the literature was reviewed, in only one report was freeze-dried bone used in periodontal defects. In this report, Hurt used dogs as his experimental model and created artificial two-wall bony defects about the maxillary cuspids. Half of the defects were treated by subgingival curettage, while the other half were packed with freeze-dried allograft bone. Clinically, there were no noticeable differences when the control and experimental sides were examined. However, histologically there was convincing evidence that the freeze-dried bone promoted osseous obliteration of the defects. Hurt suggests that freeze-dried bone may have some potential in periodontal therapy. A study is in progress to determine if this is, in fact, true. This paper reports the current findings from a longitudinal study using freeze-dried crushed cortical bone as a graft material in human periodontal defects.
JOSEPH J . L A W R E N C E , D.D.S., M . S . H
41
R E F O R M A T I O N O F L O S T alveolar bone and restoration of a
functional attachment apparatus is the primary goal of periodontal osseous grafting procedures. T o achieve this goal, a wide variety of grafting materials has been employed. Autogenous bone appears to offer the greatest degree of success, but this material has certain limitations. The clinician faces the problem of obtaining sufficient quantities of autogenous bone from the intra-oral donor sites for utilization in large or multiple defects, and while autogenous marrow is readily available in sufficient quantity from the iliac crest, previous studies have shown that it may induce resorption when used in a fresh state. Furthermore, the utilization of this material in the fresh or frozen state requires an additional surgical incision which results in an additional postoperative morbidity for the patient. 1-6
7-10
11
12
13-15
MATERIALS AND METHODS
The freeze-dried bone used in this investigation had been obtained from the Navy Tissue Bank, Naval Medical Research Institute, Bethesda, Maryland. The bone was procured from a sterile autopsy which had been performed within 24 hours after death. Cortical bone was removed from the tibia, fibula, or femur, was cut into strips, and cultured for bacterial contamination. It was frozen in a liquid nitrogen freezer ( - 1 9 7 ° C ) and stored at this temperature until placed in a commercial freezedrying chamber, where at least 95% of the total water content was removed under vacuum. The freeze-dried bone was ground under sterile conditions to a powderlike consistency of 100 to 300 in a Tekmar Analytical M i l l , * and placed in 1/2-oz glass bottles, which were sealed (Fig. 1) and subjected to a secondary vacuum. The bone deposit could then be safely stored at room temperature until used. The vacuum was tested periodically to insure that the seal had not been lost.
The use of freeze-dried crushed cortical bone allograft may offer a solution to some of these problems. This material is obtained under sterile conditions from a cadaver which has met the rigid criteria for tissue donation established by the Navy Tissue Bank. The bone is frozen and the tissue water is removed by the process of lyophilization. This process is commonly referred to as freeze-drying and is carried out under vacuum at low temperature ( - 4 0 ° C ) . 16,
1 7
* This project was supported by Bureau of Medicine and Surgery, Navy Department, under MR041.20.02.6053A3ID and Naval Medical Research Institute Research task M4318.01.0002BGJ2. †The opinions or assertions contained herein are the private ones of the writers and are not to be construed as official or as reflecting the views of the Navy Department or the naval service at large. ‡Periodontics Section, U.S. Naval Station, Box 12, FPO New York 09551. § University of Maryland School of Dentistry, Baltimore, Maryland 21201. || Present address, Orthopedic Department, University of Florida, Gainesville, Florida 32601. 1 Periodontics Department, Naval Graduate Dental School, National Naval Medical Center, Bethesda, Md. 20014.
* Tekmar Analytical Mill, Model A-10 Tekmar Company, P.O. Box 37202, Cincinnati, Ohio 45222. 125
J. Periodontol. March, 1976
I E 3 Mellonig, Bowers, Bright, Lawrence
The collaborators were asked to reenter the graft site in 1 year and to record the amount of osseous regeneration, or lack thereof. This was to be accomplished by comparing preoperative measurements, radiographs, and photographs with similar data obtained at the time of reentry. The large number of investigators in this study precluded the use of specific millimeter measurements as the method of assessing osseous regeneration and pocket elimination. Consequently, the collaborators were permitted to measure the depth and width of defects by any method with which they were familiar. Some utilized standardized periodontal probes; others combined probing with measurements obtained with silver points or Hirschfeld points. Still other clinicians utilized threedimensional drawings plus measurements to estimate the FIGURE 1. Freeze-dried bone allograft, particle size 100 to 300 amount of osseous regeneration. In all cases, the cliniµ. The material may be stored indefinitely in this container at cians were asked to correlate the pre- and postoperative room temperature until used. measurements, radiographs, and photographs, and to estimate and record the amount of bony regeneration and pocket elimination as either complete, greater than 50%, Forty-four periodontists from military and civilian less than 50%, or none. It was felt that it was well within practices were selected to clinically evaluate the efficacy the capability of every periodontist in this study to make of freeze-dried bone in periodontal osseous defects. A l l a reasonably accurate determination of the amount of collaborators were asked to use the material in patients osseous regeneration using the aforementioned criteria. with one-wall, two-wall, widemouthed three-wall, and combination defects, as well as furcation involvements. The data obtained by the clinicians were then submitNarrow three-wall defects were excluded from this study, ted to the tissue bank, where they were compiled and since experience has shown that this defect will often tabulated by the authors. O f the 44 investigators, 37 had repair without a graft material being used. completed cases and submitted data at the time of Each patient selected for the study was required to sign an informed consent authorization form before receiving the human allograft tissue. This form stated that a graft was "obtained from another human body; that the tissue was procured, processed, and preserved in accordance with established medical procedures; that the graft was believed to be free from bacterial contamination; that the success of the transplant was not guaranteed; and that therapy was planned as a two stage procedure with the second operation to occur 1 year postgrafting to allow for evaluation and additional therapy as needed." Procedures to be accomplished preliminary to implantation of the allograft included: demonstration of effective plaque control by the patient, scaling and prophylaxis, and an adjustment of the occlusion, if indicated. Preoperative and postoperative radiographs were required and were supplemented by intraoral Kodachrome pictures prior to surgery, at the time of surgery, and at the 1-year reentry. In addition, each collaborator provided narrative summaries of the patient's general medical status, and sequential evaluations of the graft at the time of follow-up visits. The clinician was given the option of flap design, periodontal dressings, and specific antibiotic regimen. He also had the choice of whether to perform root planing and to accomplish intramarrow penetration, and whether to "fill" or "overfill" the defect. A t the completion of surgery, each clinician was required to complete the data form indicating specifically how he had managed the treatment of the patient with regard to the foregoing parameters.
submission of this report. RESULTS
Over 300 osseous defects in 189 periodontal patients have been treated with freeze-dried crushed cortical bone allografts. T o date, a total of 97 defects have been reentered in 48 patients. The patients ranged in age from 23 to 63, with a mean age of 45.9 years. There were 36 men and 12 women. Full-thickness flaps, root planing, and intramarrow penetration were employed in most cases (Table 1). The majority of clinicians stated that they "overfilled" the defect with allograft. Wound approximation was accomplished in 88 defects, but complete coverage could not be obtained in nine instances. In all cases, postoperative healing was considered normal and there were no reported clinical signs of immunologic rejection. A variety of periodontal dressings was employed, and in 7 instances dressings were not utilized. Erythromycin was the antibiotic most frequently given to the patient. There were no reports of postoperative sequestration of the graft material. Radiographically, there appeared to be complete incorporation of the graft, except that in one case it could be delineated from the surrounding bone. Root resorption and ankylosis were not observed. The amount of osseous regeneration as determined by pre- and postoperative radiographs, measurements, and photographs is summarized in Table 2. O f the 97 osseous defects treated with grafts, 23 were reported as complete bony regeneration, 39 had greater than 50% regenera-
Volume 47 Number 3
Freeze-dried Bone Allografts
effectiveness were never obtained. Over this 12-year period, large fragments of cancellous bone approximately 1 to 2 mm in diameter were employed. It was the opinion of many periodontists who used the material in this form that it was slowly, if ever, replaced with new host bone. Continued sequestration of rather large particles from the sulcus also presented some difficult management problems.
tion, and 23 had less than 50% regeneration. Twelve defects failed to demonstrate any bony fill. Thus, freezedried bone caused a 50%, or better, regeneration in 64% of the defects and stimulated a partial fill in another 24% of the cases. Figure 2 through 5 are photographs representative of osseous regeneration obtained with freeze-dried bone allografts in some of the reported defects shown in Table 2. Residual pocket depth appeared to be inversely proportional to the amount of regeneration of the defect. The greater the regeneration, the less was the pocket depth (Table 3). Twenty-four of the defects showed complete elimination of pocket depth; 44 showed greater than 50% reduction; and 25, less than 50% reduction. The pocket depth in four did not change.
A particle size of 100 to 300 f i was employed in this study in an attempt to overcome the problems observed with the larger bone chips. In addition, studies suggest that fine particles of bone (100 to 300 µ) are active in inducing regeneration of the alveolar process. The small particle size used in this study appears to have solved the problems previously encountered with the large fragments of freeze-dried bone. There have been no reports of sequestration around the wound site, and in only one case was incomplete resorption of the graft material reported. 4 2
43-45
DISCUSSION
Freeze-dried bone has been used successfully for over 20 years to treat a variety of orthopedic and oral surgical conditions. It has been also employed, on a limited basis,
It is noteworthy that there were no reports of postoperative infection and no mention of any clinical signs of immunologic rejection. Studies reported in the medical
in the management of osseous defects of the periodontium for over
12 years. Unfortunately, data on its
T A B L E 1. Surgical Data on 97 Defects
Flap type
Root planing
Intramarrow penetration
Wound closure
Wound healing
Full
Partial
Yes
No
Yes
No
Complete
Incomplete
Normal
Delayed
90
7
93
4
70
27
88
9
97
0
Type of dressing
(62) Professional Products (16) Coe-Pak (7) None (3) Baer-Sumner (3) Kirkland (1) Orahesive
Reentry postsurgery
Type of antibiotic
(59) Erythromycin (14) Tetracycline (12) KeHex
(61) (24) (8) (3) (1)
(5) Penicillin (4) None (3) Cleomycin
12 mo. 13 mo. 14 mo. 11 mo. 15 mo.
T A B L E 2. Osseous Regeneration Repair Defect morphology
Number of defects Complete
>50%
50% osseousperiodontal osseous defects. However, final determinaregeneration was reported. D . Preoperative radiograph. E, tion must await the outcome of a larger number of cases Fifteen-month postoperative radiograph. and also histologic evidence.
Volume 47 Number 3
Freeze-dried Bone Allografts
129
FIGURE 3. (Case submitted by R. W. Koch). A, A two-wall defect on the distal of the mandibular left first bicuspid. The facial and proximal walls remain. B, The graft material is shown in place. C, The graft site at I year reentry. Reported as > 50% osseous regeneration. D, Preoperative radiograph. E, One-year postoperative radiograph.
FIGURE 4. (Case submitted by C. Julienne). A , one-wall defect on the distal of the maxillary right second bicuspid. The proximal wall remains. B, Clinical appearance of the graft site at 13-month reentry. Reported as complete regeneration. C , Preoperative radiograph. D, Thirteen-month postoperative radiograph.
130
J. Periodontal. March, 1976
Mellonig, Bowers, Bright, Lawrence
FIGURE 5. (Case submitted by T. R. Tempel). A, A two-wall defect on the mesiolingual of the maxillary left central and a two to three-wall combination defect on the mesial, lingual, and distal of the maxillary left lateral. B, The defects are shown at time of surgery with freeze-dried bone in place. C, Appearance of graft site at I year reentry. Both defects reported as complete regeneration. D, Preoperative radiograph. E, One-year postoperative radiograph.
T A B L E 3. Pocket Elimination Defect morphology
Number of defects
Complete
Widemouthed three-wall Two-wall One-wall Combination one to two-wall Combination one to three-wall Combination two to three-wall Furcation
18 15 18 12 7 14 13
4 5 4 4 2 4 1
Total
97
Percentage
100%
>50%
