Due to circumstances mentioned
Lyophilized Bone Alìografts in Periodontal Intraosseous Defects*
F.A.C.d.
d.d.s., m.s.d.
In the early 1970's, it appeared that the search for an ideal periodontal osseous tissue graft was at an end. Schallhorn et al.,1 as well as others,2"4 had shown that significant osseous regeneration occurred after the use of autogenous grafts taken either from the iliac crest or from intraoral sources.5"9 Although the osteogenic potential of this material was better than that of any previously tested materials, it did not represent an "ideal" graft because of the limited quantity available from the intraoral source and the need for a second surgical insult with both sources. So, the search for the ideal graft was
renewed.10"17
One material that seemed to have great promise was the freeze-dried powdered cortical allograft.15'17 Treatment of more than 800 defects in 350 patients was reported, with reentry in 189 of these sites. The reentry evaluation reported that greater than 50% osseous regeneration occurred in 60% of the patients. However, as pointed out by the authors, these studies lacked controls and histologie data to substantiate their findings. Some histologie data are available but as yet are unreported.18 Controlled clinical studies are missing from the literature. In an attempt to verify the reported effectiveness of freeze-dried cortical powdered allografts, the following controlled clinical study was conducted. Materials
and
of
cadaver within 24 hours of death. The donor was free from all generalized viral and bacterial contamination, contagious disease, malignancies, and the administration of long half-life isotopes and long-term medications known to affect bone (that is, corticosteroids). The shaft of the left femur of a 21-year-old trauma victim was removed and frozen in liquid nitrogen. It was transported under aseptic technique to a sterile hood, where it was split longitudinally, and all cancellous bone and marrow elements were removed and discarded. In 1976, Spence et al.23 showed that cortical bone is superior to cancellous bone when used as a freeze-dried homograft in osseous defects. The opposite may be true in grafts—a situation in which most investigaautogenous 24-26 tors9' believe that cancellous bone is superior. However, no definitive studies have compared these two types of osseous tissue. The cortical plates were reduced in size to approximately 1 to 2 cm and repeatedly washed in sterile saline to remove all traces of blood elements. The bone chips were lyophilized in a sterile commercial freeze-drying chamber. At the end of approximately 2 weeks, at least 95% of the total water content had been removed. The lyophilized bone was ground under sterile conditions (Tekmar Analytical 11) to a powdery consistency. The powder was screened through a sterile sieve with 400 fim openings. Particle size was reduced in the present study because previous studies27-29 suggested that fine-particle bone size is more active in inducing Osteogenesis. Material that did not pass through the sieve was reground. The powdered bone was then sealed in sterile 5-ml vials (approximately 2 g per vial), which were then air-evacuated. The vials were tested periodically during the study to ensure that the vacuum had been maintained. This method provided a graft with an indefinite shelf life.30 Sample vials of the prepared bone, selected at random, were cultured for bacterial, viral, or fungal contamination. Two of 12 specimens submitted were positive for Propionebacteriwn acnes organisms. Although this may have represented a laboratory contaminant, all donor bone was subjected to irradiation to ensure sterilization (3 million rads).§ After irradiation of the graft material, microbiology studies were repeated, and the results were negative. The donor bone was ready for transplantation
Eugene T. Altiere, d.d.s., m.s.d.f Charles M. Reeve, d.d.s., m.s.,
Sheridan,
manner
on a
by
Phillip J.
below, the
preparation did vary slightly. The bone used in the freeze-drying process (lyophilization)19-22 was obtained by performing sterile autopsy
Methods
The technique of graft preparation utilized in this study was developed by the US Navy Tissue Bank and is essentially the same as that used in the only published human periodontal grafting studies of this material.15,17 * This paper was abstracted from a study submitted by the senior author in partial fulfillment of the requirements for a Master of Science Degree in Dentistry, Mayo Graduate School of Medicine, University of Minnesota. First place winner in the Balint Orban Memorial Program at the 1978 meeting of the American Academy of Periodontology in Phoenix, Arizona. From the Department of Dentistry, Section of Periodontics, Mayo Clinic and Mayo Foundation, Rochester, 55901. 55802. t Present address: 1229 Medical Arts Building, Duluth, Reprint address: Dr. E. T. Altiere, % Section of Publications, Mayo 55901. Clinic, 200 First Street Southwest, Rochester,
procedures.
Patients were selected from the private group periodontal practice of the Mayo Clinic. The criterion for selection was based on the presence of bilateral, "mirrorTekmar Analytical Mill, Model A-10, Tekmar Co., P. O. Box 37202, Cincinnati, OH. § Neutron Products, Dickerson, MD.
510
Volume 50 Number 10
Lyophilized Bone A llografis
intraosseous defects. In this way, grafting and reattachment procedures could be compared in a situation in which the control defect was identical to the graft site, and each patient could serve as his own control. The left or the right defect, randomly selected, was treated with a graft, and the contralateral side was treated with flap and curettage procedures. Only defects reportedly resistant to new conservative attachment were included in the study. Each patient was advised that the 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 of contamination, and that the success of the transplant was not guaranteed. All patients were instructed that the therapy was planned as a two-stage procedure, with the second stage involving evaluation of results, and additional definitive osseous therapy, if necessary, being done 1 year after grafting. Nine patients with 10 pairs of intraosseous periodontal defects were treated; the 3 males and 6 females had a mean age of 37 years. In each pair of defects, one of the defects was treated by a flap and curettage control procedure and the other was grafted with freeze-dried cortical powdered homogeneous bone. Six of the pairs represented "mirror-image" lesions, with the defects being identical but on opposite sides of the mouth. Of the other four pairs, three involved lesions on the opposite side of the mouth but not on the exact contralateral tooth, and one involved unconnected mesial and distal lesions on the same tooth. The preoperative data involved the patient's name, address, and date of birth, referring dentist, defect site chosen for study; periodontal charting including clinical pocket depths (height of gingiva to depth of sulcus) and specific measurements of the defects chosen for study (using an Omnivac* Stent as a reference point),34 tooth vitality, and a subjective clinical evaluation of the patient's oral hygiene. Comprehensive medical histories were available for all patients and were reviewed for significant systemic data. In addition, maxillary and mandibular models and full-mouth intraoral photographs (Kodachrome) were made. Additional preoperative data consisted of a full-mouth series of intraoral radiographs plus individual films of three specific areas: graft site (Fig. 1A), control site (Fig. 2A), and site at which no surgery was attempted. Radiographs were retaken approximately 2, 12, 24, 36, and 48 weeks after operation (Fig. IB and 2B), using a modified Rinnf paralleling device35"37 that had been personalized for each patient with an acrylic resin bite registration to ensure precise duplicate placement of film and x-ray cone head. The same x-ray cone head was used for all radiographs, and the settings for time, milliamperes, and kilovolt (peak) were recorded and subsequently reused
image"
procedures31"33
Omnidental Corp., Harrisburg, PA. t Rinn XCP Instrument, Rinn Corp.,
511
patient. A pure aluminum circular step wedge incorporated into each radiograph to serve as a standard for comparison between radiographs in videodensitometric analysis, which was done and which will be reported at another time. Although most periodontal grafting studies have used either a Hirschfeld point38 or a Fixott-Everett grid39 to demonstrate pocket depths, it was impractical in this study because opacity of the marker would have made scanning videodensitometry, as employed in another portion of this study, an impossibility. Preliminary procedures accomplished before implantation included oral hygiene instruction, scaling, occlusal adjustment if indicated, root planing and curettage, and demonstration of effective plaque control by the patient. Surgery was performed either in the dental office under local anesthesia or in a hospital under general anesthesia. In either situation, the surgical procedures were identical. A mucoperiosteal flap was elevated. The intact-papilla flap technique40 was used in the graft and on
each
was
control sites. In other areas, a conventional, inverse bevel incision was utilized. After epithelium and granulation tissue were removed, and the root surface was planed to a smooth, hard consistency, the surgical site was irrigated with sterile saline to aid in the debridement of the defect. The deepest aspect of the osseous defect being studied was then measured, using a standardized periodontal probe with the cementoenamel junction as a reference point. Care was always taken to ensure that the probe was aligned parallel to the long axis of the tooth and wedged interproximally against the contact area so as to make future alignment of the probe consistent. At this time, buccal and lingual views (Kodachrome) of the surgical site were made (Fig. 3A, 4A, 5A, and 6A), and a verbal description of the bony defect was recorded. The cortical bone of the defect was then perforated with a No. lh round burr to permit egress of multipotential cells of the marrow spaces.41 The freeze-dried bone was prepared by placing the graft material in a dappen dish and adding sterile saline, a drop at a time, until a thick paste-like consistency was obtained. The osseous material was then "packed" or molded into the bony defect with a sterile amalgam carrier so that it was overfilled slightly but not enough to interfere with flap closure. Once opened, the container of freeze-dried bone was not used again. The flap was then replaced and sutured in position with 3-0 silk so that the surgical site was completely covered. The control sites were treated in an identical manner, with the exception of a graft not being placed. Also, all surgical periodontal therapy deemed necessary in other parts of the mouth was carried out at this time, and a surgical periodontal dressing^ was applied. The sutures and dressing were removed at 7 days, and a new dressing was applied for another 7 days.
*
1212 Abbott
Drive, Elgin, IL.
% COE-PAC
Periodontal Paste, COE
Laboratory, Chicago,
IL.
512
J. Periodontol. October, 1979
Altiere, Reeve, Sheridan
Figure 1.
Graft site. A, Preoperative. , Postoperative (9 months).
Follow-up visits for evaluation of healing, sequential radiographs, and maintenance of hygiene occurred postoperatively at approximately 1 week, 2 weeks, 1 month, 3
months, 6 months, 9 months, and 1 year.
Approximately
1 year after surgery, all measurements
and evaluations done originally, including charting, photographs, and models, were repeated. Surgical reentry was performed on all 10 pairs from 40 to 50 weeks after transplantation, with most occurring at 48 weeks. Reentry procedures were performed on the graft and control
J. Periodontol. October, 1979
Altiere, Reeve, Sheridan
514
sites, duplicating the surgical and data recording procedures performed at the initial surgery (Fig. 3B, 4B, 5B,
Table 3. Osseous
exception graft placement. probe measurements during reentry were performed by an operator unfamiliar with the statistical design of the study (P.J.S., C.M.R.) so as not to prejudice the findings. Any necessary osseous recontouring was performed at this time. After postoperative réévaluation, patients were placed on maintenance recall, as deemed necessary. and
The
of
6B), with the
Osseous Regeneration. Osseous regeneration was evaluated in two ways. Relative growth was noted as being complete, greater than 50% fill, less than 50% fill, or failure. This method allows for measurement of clinical success, with greater than 50% fill being a clinically successful graft. The assessment was based on the correlation of preoperative and postoperative measurements, radiographs, and photographs (Kodachrome) and direct visualization both during the initial surgery and reentry, and is also in keeping with methods of analysis by previous authors.15'17 There was no difference in osseous regeneration between the graft and the control site (Tables 1 and 2). The second method was the evaluation of bone growth at a particular point. This was done by measuring from the greatest depth of the lesion to the cementoenamel junction. Graft and control data were similar (Table 3).
(Graft) Regeneration
No.
C°m"
plete Wide three wall Two wall One wall Combination of two-three wall Total Percent
10 100
>50% 15,17 success in grafting were defined as being demonstrated by "greater than 50% fill," then the grafting material investigated was successful in 60% of our cases. The graft data were statistically no different from those of the only studies using this same material.15'17 However, comparison of the graft and control data revealed not only no significant difference but also a high positive correlation between results, thus indicating that the effectiveness of grafting procedures using this material needs to be more thoroughly investigated. If,
as
in other
Lyophilized Bone Allografts 517 This study is only a pilot investigation and, because of the small number of experimental pairs, cannot provide conclusive statement rial. a
Summary
on
the effectiveness of this mate-
and
Conclusions
Nine patients with 10 pairs of intraosseous periodontal defects were treated. Most of the patients had identical bilateral lesions (referred to as "mirror-image" defects). In each pair, one of the defects was randomly selected and treated as a flap and curettage control whereas the other defect was grafted with freeze-dried cortical powdered allografts of bone. Evaluation was based on radiographs, photographs, and measurements taken during both the initial surgery and at reentry approximately 1 year after transplantation. Control procedures (flap and curettage) demonstrated the same amount of osseous regeneration as that seen with the graft procedure. The amount of osseous regeneration demonstrated with the grafting procedures agreed with previously published studies. Evaluation revealed that (1) an autologous control such as incorporated in the "mirror-image" design of this study is probably the most valid experimental model available for evaluating the clinical effectiveness of any human periodontal grafting procedures; (2) the effectiveness of freeze-dried cortical powdered bone allografts in human periodontal osseous defects is questionable and needs additional study; and (3) nongrafting procedures may be more effective in generating new attachments or reattachments in human periodontal osseous defects than previously believed. References 1. Schallhorn, R. G., Hiatt, W. H., and Boyce, W.: Iliac transplants in periodontal therapy. J Periodontol 41: 566, 1970. 2. Seibert, J. S.: Reconstructive periodontal surgery: Case
report. J Periodontol 41: 113, 1970. 3. Haggerty, P. C, and Maeda, I.: Autogenous bone grafts:
A revolution in the treatment of vertical bone defects. J Periodontol 42: 626, 1971. 4. Dragoo, M. R., and Sullivan, H. C: A clinical and histological evaluation of autogenous iliac bone grafts in humans. Part I. Wound healing 2 to 8 months. J Periodontol 44: 599, 1973. 5. Nabers, C. L., and O'Leary, T. J.: Autogenous bone transplants in the treatment of osseous defects. J Periodontol 36: 5, 1965. 6. Ross, S. E., and Cohen, D. W.: The fate of a free osseous tissue autografi: A clinical and histologie case report. Periodontics 6: 145, 1968. 7. Ellegaard, B., and Löe, H.: New attachment of periodontal tissues after treatment of intrabony lesions. J Periodontol 42:648, 1971. 8. Rosenberg, M. M.: Free osseous tissue autografts as a predictable procedure. J Periodontol 42: 195, 1971. 9. Hiatt, W. H., and Schallhorn, R. G: Intraoral transplants of cancellous bone and marrow in periodontal lesions. J Periodontol 44: 194, 1973. 10. Hiatt, W. H., and Schallhorn, R. G.: Human allografts of iliac cancellous bone and marrow in periodontal osseous
518
J. Periodontol. October, 1979
Altiere, Reeve, Sheridan
defects. I. Rationale and methodology. J Periodontol 42: 642, 1971. 11. Klingsberg, J.: Preserved sclera in periodontal surgery. J Periodontol 43: 634, 1972. 12. Klingsberg, J.: Periodontal scierai grafts and combined grafts of sclera and bone: Two-year appraisal. J Periodontol 45: 262, 1974. 13. Register, . .: Bone and cementum induction by dentin, demineralized in situ. J. Periodontol 44: 49, 1973. 14. Libin, . M., Ward, H. L., and Fishman, L.: Decalcified, lyophilized bone allografts for use in human periodontal defects. J Periodontol 46: 51, 1975. 15. Mellonig, J. T., Bowers, G. M., Bright, R. W., and Lawrence, J. J.: Clinical evaluation of freeze-dried bone allografts in periodontal osseous defects. J Periodontol 47: 125, 1976. 16. Haggerty, P. C: Human allografts—the efficient therapeutic approach to the infrabony defect. J Periodontol 48: 743, 1977. 17. Sepe, W. W., Bowers, G. M., Lawrence, J. J., Friedlaender, G. E., and Koch, R. W.: Clinical evaluation of freezedried bone allografts in periodontal osseous defects. Part II. J Periodontol 49: 9, 1978. 18. Moomaw, R. C: A clinical, radiographie, and histological evaluation of freeze-dried allogeneic bone grafts in human periodontal defects. Thesis, University of North Carolina, Asheville, 1975. 19. Flosdorf, E. W.: Freeze-Drying. Drying by Sublimation, New York, Reinhold Publishing Corporation, 1949. 20. Flosdorf, E. W., and Hyatt, G. W.: The preservation of bone grafts by freeze-drying. Surgery 31: 716, 1952. 21. Kreuz, F. P., Hyatt, G. W., Turner, T. C, and Bassen, A. L.: The preservation and clinical use of freeze-dried bone. J Bone Joint Surg [Am] 33: 863, 1951. 22. Pappas, A. M.: Current methods of bone storage by freezing and freeze-drying. Cryobiology 4: 358, 1968. 23. Spence, K. F., Jr., Bright, R. W., Fitzgerald, S. P., and Sell, K. W.: Solitary unicameral bone cyst: Treatment with freeze-dried crushed cortical-bone allograft; a review of one hundred and forty-four cases. J Bone Joint Surg [Am] 58: 636, 1976. 24. Halliday, D. G.: The grafting of newly formed autogenous bone in the treatment of osseous defects. / Periodontol 40: 511, 1969. 25. Rosenberg, M. M.: Reentry of an osseous defect treated by a bone implant after a long duration. J Periodontol 42: 360, 1971. 26. Burwell, R. G: Studies in the transplantation of bone. VII. The fresh composite homograft-autograft of cancellous bone: An analysis of factors leading to Osteogenesis in marrow transplants and in marrow-containing bone grafts. J Bone Joint Surg [Br] 46: 110, 1964. 27. Robinson, R. E.: Osseous coagulum for bone induction. J Periodontol 40: 503, 1969. 28. Diem, C. R., Bowers, G. M., and Moffitt, W. C: Bone blending: A technique for osseous implants. J Periodontol 43: 295, 1972. 29. Rivault, A. F., Toto, P. D., Levy, S., and Gargiulo, A. W.: Autogenous bone grafts: Osseous coagulum and osseous retrograde procedures in primates. J Periodontol 42: 787, 1971. 30. Turner, T. C, Bassen, C. A. L., Pate, J. W., and Sawyer, P. N.: An experimental comparison of freeze-dried and frozen cortical bone-graft healing. J Bone Joint Surg [Am] 37: 1197, 1955. 31. Prichard, J.: The infrabony technique as a predictable procedure. J Periodontol 28: 202, 1957. 32. Prichard, J.: Regeneration of bone following periodontal therapy: Report of cases. Oral Surg 10: 247, 1957.
33. Goldman, H. M., and Cohen, D. W.: The infrabony Classification and treatment. J Periodontol 29: 272, 1958. 34. Froum, S. J., Thaler, R., Scopp, I. W., and Stahl, S. S.: Osseous autografts. I. Clinical responses to bone blend or hip marrow grafts. J Periodontol 46: 515, 1975. 35. Updegrave, W. J.: Simplified and standardized bisecting-angle technic for dental radiography. J Am Dent Assoc 75: 1361, 1967. 36. Updegrave, W. J.: Right-angle dental radiography. Dent Clin North Am November, 571, 1968. 37. Matsue, I., Collings, C. K., Zimmerman, E. R., and Vail, W. C: Microdensitometric analysis of human autogenous alveolar bone implants. / Periodontol 41: 489, 1970. 38. Hirschfeld, L.: A calibrated silver point for periodontal diagnosis and recording. J Periodontol 7A: 94, 1953. 39. Everett, F. G., and Fixott, H. C: Use of an incorporated grid in the diagnosis of oral roentgenograms. Oral Surg 16: 1061, 1963. 40. App, G. R.: Periodontal treatment for the removable partial prosthesis patient: Another half-century? Dent Clin North Am 17: 601, 1973. 41. Nabers, C. L., and O'Leary, T. J.: Autogenous bone grafts: Case report. Periodontics 5: 251, 1967. 42. Kramer, G. M.: Rationale of periodontal therapy. Goldman, H. M. and Cohen, D. W. (eds), Periodontal Therapy, pp 327-344, St. Louis, C. V. Mosby Company, 1973. 43. Turner, T. C, Bassett, C. A. L., Pate, J. W., and Sawyer, P. N: Sterilization of preserved bone grafts by high-voltage cathode irradiation. J Bone Joint Surg [Am] 38: 862, 1956. 44. Heiple, K. G., Chase, S. W., and Herndon, C. H.: A comparative study of the healing process following different types of bone transplantation. J Bone Joint Surg [Am] 45: 1593, 1963. 45. Chalmers, J., Lea, L., Stewart, L., and Sissons, . .: Freeze-dried bone as a grafting material. Parkes, A. S. and Smith, A. U. (eds.), Recent Research in Freezing and Drying, Oxford, Blackwell Scientific Publications, 1960. 46. Burwell, R. G.: Studies in the transplantation of bone. VIII. Treated composite homograft-autografts of cancellous bone: An analysis of inductive mechanisms in bone transplantation. J Bone Joint Surg [Br] 48: 532, 1966. 47. Brooks, D. B., Heiple, K. G., Herndon, C. H., and Powell, A. E.: Immunological factors in homogenous bone transplantation. IV. The effect of various methods of preparation and irradiation on antigenicity. J Bone Joint Surg [Am] 45: 1617, 1963. 48. Buring, K., and Urist, M. R.: Effects of ionizing radiation on the bone induction principle in the matrix of bone implants. Clin Orthop 55: 225, 1967. 49. Patur, ., and Glickman, I.: Clinical and roentgenographic evaluation of the post treatment healing of infrabony pockets. / Periodontol 33: 164, 1962. 50. Cross, W. G.: Bone implants in periodontal diseases—a further study. J Periodontol 28: 184, 1957. 51. Schluger, S., Yuodelis, R. ., and Page, R. C: Periodontal Disease: Basic Phenomena, Clinical Management, and Occlusal and Restorative Interrelationships, p. 527. Philadelphia, Lea & Febiger, 1977. 52. Friedlaender, G. E., Strong, D. M., and Sell, K. W.: Studies on the antigenicity of bone. I. Freeze-dried and deepfrozen bone allografts in rabbits. J Bone Joint Surg [Am] 58: 854, 1976. 53. Schallhorn, R. G., and Hiatt, W. H.: Human allografts of iliac cancellous bone and marrow in periodontal osseous defects. II. Clinical observations. / Periodontol 43: 67, 1972. 54. Goldman, H. M.: A rationale for the treatment of the intrabony pocket: One method of treatment, subgingival curet-
pocket:
Volume 50 Number 10
Lyophilized Bone A llografts
tage. J Periodontol 20: 83, 1949. 55. Glavind, L., and Löe, H.: Errors in the clinical assessment of periodontal destruction. / Periodont Res 2: 180, 1967. 56. Sivertson, J. F., and Burgett, F. G.: Probing of pockets related to the attachment level. J Periodontol 47: 281, 1976. 57. Friedman, N.: Reattachment and roentgenograms. / Periodontol 29: 98, 1958. 58. Goldman, H. M., and Stallard, R. E.: Limitations of the
radiograph in the diagnosis of osseous defects in periodontal disease. / Periodontol 44: 626, 1973. 59. Patur, B.: Osseous defects: Evaluation of diagnostic and treatment methods. J Periodontol 45: 523, 1974. 60. Prichard, J.: A technique for treating infrabony pockets based on alveolar process morphology. Dent Clin North Am March, 85, 1960. 61. Pfeifer, J. S.: The present status of bone grafts in periodontal therapy. Dent Clin North Am 13: 193, 1969. 62. Pfeifer, J. S.: What is the place of bone grafts in periodontal therapy. Periodont Abstr 14: 150, 1967. 63. Froum, S. J., Ortiz, M., Witkin, R. T., Thaler, R., Scopp, I. W., and Stahl, S. S.: Osseous autografts. III. Comparison of osseous coagulum-bone blend implants with open curettage. J Periodontol 47: 287, 1976. 64. Yuktanandana, I.: Bone graft in the treatment of intrabony periodontal pocket in dogs: A histological investigation. J Periodontol 30: 17, 1959.
519
65. Ellegaard, B., Karring, T., Listgarten, M., and Löe, H.: New attachment after treatment of interradicular lesions. J Periodontol 44: 209, 1973. 66. Ellegaard, B., Karring, T., Davies, R., and Löe, H.: New attachment after treatment of intrabony defects in monkeys. J
Periodontol 45: 368, 1974. 67. Hurt, W. C: Freeze-dried bone homografts in periodontal lesions in dogs. J Periodontol 39: 89, 1968. 68. Schallhorn, R.: Eradication of bifurcation defects utilizing frozen autogenous hip marrow implants. Periodont Abstr 15: 101, 1967. 69. Schallhorn, R. G.: The use of autogenous hip marrow biopsy implants for bony crater defects. J Periodontol 39: 145, 1968. 70. Nabers, C. L., Reed, O. M., and Hamner, J. E., Ill: Gross and histologie evaluation of an autogenous bone graft 57 months postoperatively. J Periodontol 43: 702, 1972. 71. Schaffer, E. M., and Zander, . .: Histological evidence of reattachment of periodontal pockets. Paradentologie 7: 101, 1953. 72. Hirschfeld, L., and Wasserman, B.: A long-term survey of tooth loss in 600 treated periodontal patients. J Periodontol 49: 225, 1978. 73. Lane, S. W., Guggenheim, B., and Egyedi, P.: Comparison of homogenous freeze-dried and fresh autogenous bone grafts in the monkey mandible. J Oral Surg 30: 649, 1972.
Abstracts Effect
of
Lithium
upon
Plaque
and
Gingivitis
in the
Beagle
Dog
McDonald, J. L., Jr., Schemehorn, B. R., and J Dent Res 57: 474, March, 1978.
Stookey,
G. K.
One week before initiation of the study, 20 male Beagle dogs received a prophylaxis, and 24 hours before initiation, baseline gingivitis scores were obtained and all buccal plaque accumulations were removed. Based on the gingivitis scores three groups were created and the following drinking water provided: (a) deionized water; (b) deionized water containing 25 ppm lithium added as LiCl; and (c) deionized water containing 100 ppm lithium added as LiCl. After 4 weeks on this regimen the dogs were evaluated for plaque and gingivitis and no significant differences in plaque and gingivitis were found between the groups. Possible toxic manifestations were observed, so that for the third group (receiving 100 ppm) the experiment was terminated midway. Oral Health Research Institute, Indiana University School of Dentistry, 410 Beatty Avenue, Indianapolis, Ind 46202. Dr. Philip Pack Effect
of
Experimental Neutropenia on Oral Wound Healing in Guinea Pigs
Andersen, L., Attström, R., and Fejerskov, O. Scand J Dent Res 86: 237, July, 1978. The effect of experimental neutropenia on the oral wound healing process was studied in 16 guinea pigs while corresponding wounds in 15 normal animals were used as controls. Daily injections of heterologous anti-neutrophil serum were given to induce neutropenia and thus reduce circulating neutrophils. Biopsies of palatal mucosa were taken 6, 24, 48, and 120 hours after wounding. Animals treated with antiserum had a distinct decrease in the number of neutrophils in the wound
cavities while the number of mononuclear cells remained the same in both the neutropenia and control wounds. Bacterial invasion was much deeper in the neutroperiic wounds but the rate of re-epithelialization was the same in both groups. It was concluded that neutrophils are the principal agents for host defense and indirectly determine the direction and level of epithelial cell migration. Department of Oral Pathology,
Royal Dental College, Vennelyst Boulevard, DK-8000, Aarhus, C, DenDr. Philip Pack mark. of 12 Year Old Inner-City Children Relationship to Oral Health
Snack Food Consumption and its
Clancy, K. L., Goldberg, H. J. V., and Ritz, A. J Public Health Dent 38: 227, Summer, 1978. Dental examinations were performed on 92 12-year-old children from three inner-city schools. The group was divided into 48 females and 44 males who were either black or had a Spanish surname. The presence or absence of both oral debris and gingivitis were tabulated by using a disclosing solution, the Gingival Index, and the Greene and Vermillion Oral Hygiene Index. Relationships between frequency of consumption of 18 common snack foods, sex variables, and oral health scores were noted. Although only few relevant relationships between intake of snack foods and overall oral health could be demonstrated, it was found that both black male and female children had substantially higher levels of gingivitis, decayed teeth and oral debris than the other children studied. Reported frequency of eating cake and cupcakes was shown to be correlated with total oral debris and gingivitis. Consumption of chewy candy and ice cream had a definite positive correlation with total DMF scores. A problem related to this type of study is the unknown actual sucrose content of many snack foods. Department of Dental Research, University of Rochester School of Medicine and DenDr. Walter Sepura tistry, Rochester, NY 14642.
Lyophilized Bone Alìografts in Periodontal Intraosseous Defects*
F.A.C.d.
d.d.s., m.s.d.
In the early 1970's, it appeared that the search for an ideal periodontal osseous tissue graft was at an end. Schallhorn et al.,1 as well as others,2"4 had shown that significant osseous regeneration occurred after the use of autogenous grafts taken either from the iliac crest or from intraoral sources.5"9 Although the osteogenic potential of this material was better than that of any previously tested materials, it did not represent an "ideal" graft because of the limited quantity available from the intraoral source and the need for a second surgical insult with both sources. So, the search for the ideal graft was
renewed.10"17
One material that seemed to have great promise was the freeze-dried powdered cortical allograft.15'17 Treatment of more than 800 defects in 350 patients was reported, with reentry in 189 of these sites. The reentry evaluation reported that greater than 50% osseous regeneration occurred in 60% of the patients. However, as pointed out by the authors, these studies lacked controls and histologie data to substantiate their findings. Some histologie data are available but as yet are unreported.18 Controlled clinical studies are missing from the literature. In an attempt to verify the reported effectiveness of freeze-dried cortical powdered allografts, the following controlled clinical study was conducted. Materials
and
of
cadaver within 24 hours of death. The donor was free from all generalized viral and bacterial contamination, contagious disease, malignancies, and the administration of long half-life isotopes and long-term medications known to affect bone (that is, corticosteroids). The shaft of the left femur of a 21-year-old trauma victim was removed and frozen in liquid nitrogen. It was transported under aseptic technique to a sterile hood, where it was split longitudinally, and all cancellous bone and marrow elements were removed and discarded. In 1976, Spence et al.23 showed that cortical bone is superior to cancellous bone when used as a freeze-dried homograft in osseous defects. The opposite may be true in grafts—a situation in which most investigaautogenous 24-26 tors9' believe that cancellous bone is superior. However, no definitive studies have compared these two types of osseous tissue. The cortical plates were reduced in size to approximately 1 to 2 cm and repeatedly washed in sterile saline to remove all traces of blood elements. The bone chips were lyophilized in a sterile commercial freeze-drying chamber. At the end of approximately 2 weeks, at least 95% of the total water content had been removed. The lyophilized bone was ground under sterile conditions (Tekmar Analytical 11) to a powdery consistency. The powder was screened through a sterile sieve with 400 fim openings. Particle size was reduced in the present study because previous studies27-29 suggested that fine-particle bone size is more active in inducing Osteogenesis. Material that did not pass through the sieve was reground. The powdered bone was then sealed in sterile 5-ml vials (approximately 2 g per vial), which were then air-evacuated. The vials were tested periodically during the study to ensure that the vacuum had been maintained. This method provided a graft with an indefinite shelf life.30 Sample vials of the prepared bone, selected at random, were cultured for bacterial, viral, or fungal contamination. Two of 12 specimens submitted were positive for Propionebacteriwn acnes organisms. Although this may have represented a laboratory contaminant, all donor bone was subjected to irradiation to ensure sterilization (3 million rads).§ After irradiation of the graft material, microbiology studies were repeated, and the results were negative. The donor bone was ready for transplantation
Eugene T. Altiere, d.d.s., m.s.d.f Charles M. Reeve, d.d.s., m.s.,
Sheridan,
manner
on a
by
Phillip J.
below, the
preparation did vary slightly. The bone used in the freeze-drying process (lyophilization)19-22 was obtained by performing sterile autopsy
Methods
The technique of graft preparation utilized in this study was developed by the US Navy Tissue Bank and is essentially the same as that used in the only published human periodontal grafting studies of this material.15,17 * This paper was abstracted from a study submitted by the senior author in partial fulfillment of the requirements for a Master of Science Degree in Dentistry, Mayo Graduate School of Medicine, University of Minnesota. First place winner in the Balint Orban Memorial Program at the 1978 meeting of the American Academy of Periodontology in Phoenix, Arizona. From the Department of Dentistry, Section of Periodontics, Mayo Clinic and Mayo Foundation, Rochester, 55901. 55802. t Present address: 1229 Medical Arts Building, Duluth, Reprint address: Dr. E. T. Altiere, % Section of Publications, Mayo 55901. Clinic, 200 First Street Southwest, Rochester,
procedures.
Patients were selected from the private group periodontal practice of the Mayo Clinic. The criterion for selection was based on the presence of bilateral, "mirrorTekmar Analytical Mill, Model A-10, Tekmar Co., P. O. Box 37202, Cincinnati, OH. § Neutron Products, Dickerson, MD.
510
Volume 50 Number 10
Lyophilized Bone A llografis
intraosseous defects. In this way, grafting and reattachment procedures could be compared in a situation in which the control defect was identical to the graft site, and each patient could serve as his own control. The left or the right defect, randomly selected, was treated with a graft, and the contralateral side was treated with flap and curettage procedures. Only defects reportedly resistant to new conservative attachment were included in the study. Each patient was advised that the 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 of contamination, and that the success of the transplant was not guaranteed. All patients were instructed that the therapy was planned as a two-stage procedure, with the second stage involving evaluation of results, and additional definitive osseous therapy, if necessary, being done 1 year after grafting. Nine patients with 10 pairs of intraosseous periodontal defects were treated; the 3 males and 6 females had a mean age of 37 years. In each pair of defects, one of the defects was treated by a flap and curettage control procedure and the other was grafted with freeze-dried cortical powdered homogeneous bone. Six of the pairs represented "mirror-image" lesions, with the defects being identical but on opposite sides of the mouth. Of the other four pairs, three involved lesions on the opposite side of the mouth but not on the exact contralateral tooth, and one involved unconnected mesial and distal lesions on the same tooth. The preoperative data involved the patient's name, address, and date of birth, referring dentist, defect site chosen for study; periodontal charting including clinical pocket depths (height of gingiva to depth of sulcus) and specific measurements of the defects chosen for study (using an Omnivac* Stent as a reference point),34 tooth vitality, and a subjective clinical evaluation of the patient's oral hygiene. Comprehensive medical histories were available for all patients and were reviewed for significant systemic data. In addition, maxillary and mandibular models and full-mouth intraoral photographs (Kodachrome) were made. Additional preoperative data consisted of a full-mouth series of intraoral radiographs plus individual films of three specific areas: graft site (Fig. 1A), control site (Fig. 2A), and site at which no surgery was attempted. Radiographs were retaken approximately 2, 12, 24, 36, and 48 weeks after operation (Fig. IB and 2B), using a modified Rinnf paralleling device35"37 that had been personalized for each patient with an acrylic resin bite registration to ensure precise duplicate placement of film and x-ray cone head. The same x-ray cone head was used for all radiographs, and the settings for time, milliamperes, and kilovolt (peak) were recorded and subsequently reused
image"
procedures31"33
Omnidental Corp., Harrisburg, PA. t Rinn XCP Instrument, Rinn Corp.,
511
patient. A pure aluminum circular step wedge incorporated into each radiograph to serve as a standard for comparison between radiographs in videodensitometric analysis, which was done and which will be reported at another time. Although most periodontal grafting studies have used either a Hirschfeld point38 or a Fixott-Everett grid39 to demonstrate pocket depths, it was impractical in this study because opacity of the marker would have made scanning videodensitometry, as employed in another portion of this study, an impossibility. Preliminary procedures accomplished before implantation included oral hygiene instruction, scaling, occlusal adjustment if indicated, root planing and curettage, and demonstration of effective plaque control by the patient. Surgery was performed either in the dental office under local anesthesia or in a hospital under general anesthesia. In either situation, the surgical procedures were identical. A mucoperiosteal flap was elevated. The intact-papilla flap technique40 was used in the graft and on
each
was
control sites. In other areas, a conventional, inverse bevel incision was utilized. After epithelium and granulation tissue were removed, and the root surface was planed to a smooth, hard consistency, the surgical site was irrigated with sterile saline to aid in the debridement of the defect. The deepest aspect of the osseous defect being studied was then measured, using a standardized periodontal probe with the cementoenamel junction as a reference point. Care was always taken to ensure that the probe was aligned parallel to the long axis of the tooth and wedged interproximally against the contact area so as to make future alignment of the probe consistent. At this time, buccal and lingual views (Kodachrome) of the surgical site were made (Fig. 3A, 4A, 5A, and 6A), and a verbal description of the bony defect was recorded. The cortical bone of the defect was then perforated with a No. lh round burr to permit egress of multipotential cells of the marrow spaces.41 The freeze-dried bone was prepared by placing the graft material in a dappen dish and adding sterile saline, a drop at a time, until a thick paste-like consistency was obtained. The osseous material was then "packed" or molded into the bony defect with a sterile amalgam carrier so that it was overfilled slightly but not enough to interfere with flap closure. Once opened, the container of freeze-dried bone was not used again. The flap was then replaced and sutured in position with 3-0 silk so that the surgical site was completely covered. The control sites were treated in an identical manner, with the exception of a graft not being placed. Also, all surgical periodontal therapy deemed necessary in other parts of the mouth was carried out at this time, and a surgical periodontal dressing^ was applied. The sutures and dressing were removed at 7 days, and a new dressing was applied for another 7 days.
*
1212 Abbott
Drive, Elgin, IL.
% COE-PAC
Periodontal Paste, COE
Laboratory, Chicago,
IL.
512
J. Periodontol. October, 1979
Altiere, Reeve, Sheridan
Figure 1.
Graft site. A, Preoperative. , Postoperative (9 months).
Follow-up visits for evaluation of healing, sequential radiographs, and maintenance of hygiene occurred postoperatively at approximately 1 week, 2 weeks, 1 month, 3
months, 6 months, 9 months, and 1 year.
Approximately
1 year after surgery, all measurements
and evaluations done originally, including charting, photographs, and models, were repeated. Surgical reentry was performed on all 10 pairs from 40 to 50 weeks after transplantation, with most occurring at 48 weeks. Reentry procedures were performed on the graft and control
J. Periodontol. October, 1979
Altiere, Reeve, Sheridan
514
sites, duplicating the surgical and data recording procedures performed at the initial surgery (Fig. 3B, 4B, 5B,
Table 3. Osseous
exception graft placement. probe measurements during reentry were performed by an operator unfamiliar with the statistical design of the study (P.J.S., C.M.R.) so as not to prejudice the findings. Any necessary osseous recontouring was performed at this time. After postoperative réévaluation, patients were placed on maintenance recall, as deemed necessary. and
The
of
6B), with the
Osseous Regeneration. Osseous regeneration was evaluated in two ways. Relative growth was noted as being complete, greater than 50% fill, less than 50% fill, or failure. This method allows for measurement of clinical success, with greater than 50% fill being a clinically successful graft. The assessment was based on the correlation of preoperative and postoperative measurements, radiographs, and photographs (Kodachrome) and direct visualization both during the initial surgery and reentry, and is also in keeping with methods of analysis by previous authors.15'17 There was no difference in osseous regeneration between the graft and the control site (Tables 1 and 2). The second method was the evaluation of bone growth at a particular point. This was done by measuring from the greatest depth of the lesion to the cementoenamel junction. Graft and control data were similar (Table 3).
(Graft) Regeneration
No.
C°m"
plete Wide three wall Two wall One wall Combination of two-three wall Total Percent
10 100
>50% 15,17 success in grafting were defined as being demonstrated by "greater than 50% fill," then the grafting material investigated was successful in 60% of our cases. The graft data were statistically no different from those of the only studies using this same material.15'17 However, comparison of the graft and control data revealed not only no significant difference but also a high positive correlation between results, thus indicating that the effectiveness of grafting procedures using this material needs to be more thoroughly investigated. If,
as
in other
Lyophilized Bone Allografts 517 This study is only a pilot investigation and, because of the small number of experimental pairs, cannot provide conclusive statement rial. a
Summary
on
the effectiveness of this mate-
and
Conclusions
Nine patients with 10 pairs of intraosseous periodontal defects were treated. Most of the patients had identical bilateral lesions (referred to as "mirror-image" defects). In each pair, one of the defects was randomly selected and treated as a flap and curettage control whereas the other defect was grafted with freeze-dried cortical powdered allografts of bone. Evaluation was based on radiographs, photographs, and measurements taken during both the initial surgery and at reentry approximately 1 year after transplantation. Control procedures (flap and curettage) demonstrated the same amount of osseous regeneration as that seen with the graft procedure. The amount of osseous regeneration demonstrated with the grafting procedures agreed with previously published studies. Evaluation revealed that (1) an autologous control such as incorporated in the "mirror-image" design of this study is probably the most valid experimental model available for evaluating the clinical effectiveness of any human periodontal grafting procedures; (2) the effectiveness of freeze-dried cortical powdered bone allografts in human periodontal osseous defects is questionable and needs additional study; and (3) nongrafting procedures may be more effective in generating new attachments or reattachments in human periodontal osseous defects than previously believed. References 1. Schallhorn, R. G., Hiatt, W. H., and Boyce, W.: Iliac transplants in periodontal therapy. J Periodontol 41: 566, 1970. 2. Seibert, J. S.: Reconstructive periodontal surgery: Case
report. J Periodontol 41: 113, 1970. 3. Haggerty, P. C, and Maeda, I.: Autogenous bone grafts:
A revolution in the treatment of vertical bone defects. J Periodontol 42: 626, 1971. 4. Dragoo, M. R., and Sullivan, H. C: A clinical and histological evaluation of autogenous iliac bone grafts in humans. Part I. Wound healing 2 to 8 months. J Periodontol 44: 599, 1973. 5. Nabers, C. L., and O'Leary, T. J.: Autogenous bone transplants in the treatment of osseous defects. J Periodontol 36: 5, 1965. 6. Ross, S. E., and Cohen, D. W.: The fate of a free osseous tissue autografi: A clinical and histologie case report. Periodontics 6: 145, 1968. 7. Ellegaard, B., and Löe, H.: New attachment of periodontal tissues after treatment of intrabony lesions. J Periodontol 42:648, 1971. 8. Rosenberg, M. M.: Free osseous tissue autografts as a predictable procedure. J Periodontol 42: 195, 1971. 9. Hiatt, W. H., and Schallhorn, R. G: Intraoral transplants of cancellous bone and marrow in periodontal lesions. J Periodontol 44: 194, 1973. 10. Hiatt, W. H., and Schallhorn, R. G.: Human allografts of iliac cancellous bone and marrow in periodontal osseous
518
J. Periodontol. October, 1979
Altiere, Reeve, Sheridan
defects. I. Rationale and methodology. J Periodontol 42: 642, 1971. 11. Klingsberg, J.: Preserved sclera in periodontal surgery. J Periodontol 43: 634, 1972. 12. Klingsberg, J.: Periodontal scierai grafts and combined grafts of sclera and bone: Two-year appraisal. J Periodontol 45: 262, 1974. 13. Register, . .: Bone and cementum induction by dentin, demineralized in situ. J. Periodontol 44: 49, 1973. 14. Libin, . M., Ward, H. L., and Fishman, L.: Decalcified, lyophilized bone allografts for use in human periodontal defects. J Periodontol 46: 51, 1975. 15. Mellonig, J. T., Bowers, G. M., Bright, R. W., and Lawrence, J. J.: Clinical evaluation of freeze-dried bone allografts in periodontal osseous defects. J Periodontol 47: 125, 1976. 16. Haggerty, P. C: Human allografts—the efficient therapeutic approach to the infrabony defect. J Periodontol 48: 743, 1977. 17. Sepe, W. W., Bowers, G. M., Lawrence, J. J., Friedlaender, G. E., and Koch, R. W.: Clinical evaluation of freezedried bone allografts in periodontal osseous defects. Part II. J Periodontol 49: 9, 1978. 18. Moomaw, R. C: A clinical, radiographie, and histological evaluation of freeze-dried allogeneic bone grafts in human periodontal defects. Thesis, University of North Carolina, Asheville, 1975. 19. Flosdorf, E. W.: Freeze-Drying. Drying by Sublimation, New York, Reinhold Publishing Corporation, 1949. 20. Flosdorf, E. W., and Hyatt, G. W.: The preservation of bone grafts by freeze-drying. Surgery 31: 716, 1952. 21. Kreuz, F. P., Hyatt, G. W., Turner, T. C, and Bassen, A. L.: The preservation and clinical use of freeze-dried bone. J Bone Joint Surg [Am] 33: 863, 1951. 22. Pappas, A. M.: Current methods of bone storage by freezing and freeze-drying. Cryobiology 4: 358, 1968. 23. Spence, K. F., Jr., Bright, R. W., Fitzgerald, S. P., and Sell, K. W.: Solitary unicameral bone cyst: Treatment with freeze-dried crushed cortical-bone allograft; a review of one hundred and forty-four cases. J Bone Joint Surg [Am] 58: 636, 1976. 24. Halliday, D. G.: The grafting of newly formed autogenous bone in the treatment of osseous defects. / Periodontol 40: 511, 1969. 25. Rosenberg, M. M.: Reentry of an osseous defect treated by a bone implant after a long duration. J Periodontol 42: 360, 1971. 26. Burwell, R. G: Studies in the transplantation of bone. VII. The fresh composite homograft-autograft of cancellous bone: An analysis of factors leading to Osteogenesis in marrow transplants and in marrow-containing bone grafts. J Bone Joint Surg [Br] 46: 110, 1964. 27. Robinson, R. E.: Osseous coagulum for bone induction. J Periodontol 40: 503, 1969. 28. Diem, C. R., Bowers, G. M., and Moffitt, W. C: Bone blending: A technique for osseous implants. J Periodontol 43: 295, 1972. 29. Rivault, A. F., Toto, P. D., Levy, S., and Gargiulo, A. W.: Autogenous bone grafts: Osseous coagulum and osseous retrograde procedures in primates. J Periodontol 42: 787, 1971. 30. Turner, T. C, Bassen, C. A. L., Pate, J. W., and Sawyer, P. N.: An experimental comparison of freeze-dried and frozen cortical bone-graft healing. J Bone Joint Surg [Am] 37: 1197, 1955. 31. Prichard, J.: The infrabony technique as a predictable procedure. J Periodontol 28: 202, 1957. 32. Prichard, J.: Regeneration of bone following periodontal therapy: Report of cases. Oral Surg 10: 247, 1957.
33. Goldman, H. M., and Cohen, D. W.: The infrabony Classification and treatment. J Periodontol 29: 272, 1958. 34. Froum, S. J., Thaler, R., Scopp, I. W., and Stahl, S. S.: Osseous autografts. I. Clinical responses to bone blend or hip marrow grafts. J Periodontol 46: 515, 1975. 35. Updegrave, W. J.: Simplified and standardized bisecting-angle technic for dental radiography. J Am Dent Assoc 75: 1361, 1967. 36. Updegrave, W. J.: Right-angle dental radiography. Dent Clin North Am November, 571, 1968. 37. Matsue, I., Collings, C. K., Zimmerman, E. R., and Vail, W. C: Microdensitometric analysis of human autogenous alveolar bone implants. / Periodontol 41: 489, 1970. 38. Hirschfeld, L.: A calibrated silver point for periodontal diagnosis and recording. J Periodontol 7A: 94, 1953. 39. Everett, F. G., and Fixott, H. C: Use of an incorporated grid in the diagnosis of oral roentgenograms. Oral Surg 16: 1061, 1963. 40. App, G. R.: Periodontal treatment for the removable partial prosthesis patient: Another half-century? Dent Clin North Am 17: 601, 1973. 41. Nabers, C. L., and O'Leary, T. J.: Autogenous bone grafts: Case report. Periodontics 5: 251, 1967. 42. Kramer, G. M.: Rationale of periodontal therapy. Goldman, H. M. and Cohen, D. W. (eds), Periodontal Therapy, pp 327-344, St. Louis, C. V. Mosby Company, 1973. 43. Turner, T. C, Bassett, C. A. L., Pate, J. W., and Sawyer, P. N: Sterilization of preserved bone grafts by high-voltage cathode irradiation. J Bone Joint Surg [Am] 38: 862, 1956. 44. Heiple, K. G., Chase, S. W., and Herndon, C. H.: A comparative study of the healing process following different types of bone transplantation. J Bone Joint Surg [Am] 45: 1593, 1963. 45. Chalmers, J., Lea, L., Stewart, L., and Sissons, . .: Freeze-dried bone as a grafting material. Parkes, A. S. and Smith, A. U. (eds.), Recent Research in Freezing and Drying, Oxford, Blackwell Scientific Publications, 1960. 46. Burwell, R. G.: Studies in the transplantation of bone. VIII. Treated composite homograft-autografts of cancellous bone: An analysis of inductive mechanisms in bone transplantation. J Bone Joint Surg [Br] 48: 532, 1966. 47. Brooks, D. B., Heiple, K. G., Herndon, C. H., and Powell, A. E.: Immunological factors in homogenous bone transplantation. IV. The effect of various methods of preparation and irradiation on antigenicity. J Bone Joint Surg [Am] 45: 1617, 1963. 48. Buring, K., and Urist, M. R.: Effects of ionizing radiation on the bone induction principle in the matrix of bone implants. Clin Orthop 55: 225, 1967. 49. Patur, ., and Glickman, I.: Clinical and roentgenographic evaluation of the post treatment healing of infrabony pockets. / Periodontol 33: 164, 1962. 50. Cross, W. G.: Bone implants in periodontal diseases—a further study. J Periodontol 28: 184, 1957. 51. Schluger, S., Yuodelis, R. ., and Page, R. C: Periodontal Disease: Basic Phenomena, Clinical Management, and Occlusal and Restorative Interrelationships, p. 527. Philadelphia, Lea & Febiger, 1977. 52. Friedlaender, G. E., Strong, D. M., and Sell, K. W.: Studies on the antigenicity of bone. I. Freeze-dried and deepfrozen bone allografts in rabbits. J Bone Joint Surg [Am] 58: 854, 1976. 53. Schallhorn, R. G., and Hiatt, W. H.: Human allografts of iliac cancellous bone and marrow in periodontal osseous defects. II. Clinical observations. / Periodontol 43: 67, 1972. 54. Goldman, H. M.: A rationale for the treatment of the intrabony pocket: One method of treatment, subgingival curet-
pocket:
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Lyophilized Bone A llografts
tage. J Periodontol 20: 83, 1949. 55. Glavind, L., and Löe, H.: Errors in the clinical assessment of periodontal destruction. / Periodont Res 2: 180, 1967. 56. Sivertson, J. F., and Burgett, F. G.: Probing of pockets related to the attachment level. J Periodontol 47: 281, 1976. 57. Friedman, N.: Reattachment and roentgenograms. / Periodontol 29: 98, 1958. 58. Goldman, H. M., and Stallard, R. E.: Limitations of the
radiograph in the diagnosis of osseous defects in periodontal disease. / Periodontol 44: 626, 1973. 59. Patur, B.: Osseous defects: Evaluation of diagnostic and treatment methods. J Periodontol 45: 523, 1974. 60. Prichard, J.: A technique for treating infrabony pockets based on alveolar process morphology. Dent Clin North Am March, 85, 1960. 61. Pfeifer, J. S.: The present status of bone grafts in periodontal therapy. Dent Clin North Am 13: 193, 1969. 62. Pfeifer, J. S.: What is the place of bone grafts in periodontal therapy. Periodont Abstr 14: 150, 1967. 63. Froum, S. J., Ortiz, M., Witkin, R. T., Thaler, R., Scopp, I. W., and Stahl, S. S.: Osseous autografts. III. Comparison of osseous coagulum-bone blend implants with open curettage. J Periodontol 47: 287, 1976. 64. Yuktanandana, I.: Bone graft in the treatment of intrabony periodontal pocket in dogs: A histological investigation. J Periodontol 30: 17, 1959.
519
65. Ellegaard, B., Karring, T., Listgarten, M., and Löe, H.: New attachment after treatment of interradicular lesions. J Periodontol 44: 209, 1973. 66. Ellegaard, B., Karring, T., Davies, R., and Löe, H.: New attachment after treatment of intrabony defects in monkeys. J
Periodontol 45: 368, 1974. 67. Hurt, W. C: Freeze-dried bone homografts in periodontal lesions in dogs. J Periodontol 39: 89, 1968. 68. Schallhorn, R.: Eradication of bifurcation defects utilizing frozen autogenous hip marrow implants. Periodont Abstr 15: 101, 1967. 69. Schallhorn, R. G.: The use of autogenous hip marrow biopsy implants for bony crater defects. J Periodontol 39: 145, 1968. 70. Nabers, C. L., Reed, O. M., and Hamner, J. E., Ill: Gross and histologie evaluation of an autogenous bone graft 57 months postoperatively. J Periodontol 43: 702, 1972. 71. Schaffer, E. M., and Zander, . .: Histological evidence of reattachment of periodontal pockets. Paradentologie 7: 101, 1953. 72. Hirschfeld, L., and Wasserman, B.: A long-term survey of tooth loss in 600 treated periodontal patients. J Periodontol 49: 225, 1978. 73. Lane, S. W., Guggenheim, B., and Egyedi, P.: Comparison of homogenous freeze-dried and fresh autogenous bone grafts in the monkey mandible. J Oral Surg 30: 649, 1972.
Abstracts Effect
of
Lithium
upon
Plaque
and
Gingivitis
in the
Beagle
Dog
McDonald, J. L., Jr., Schemehorn, B. R., and J Dent Res 57: 474, March, 1978.
Stookey,
G. K.
One week before initiation of the study, 20 male Beagle dogs received a prophylaxis, and 24 hours before initiation, baseline gingivitis scores were obtained and all buccal plaque accumulations were removed. Based on the gingivitis scores three groups were created and the following drinking water provided: (a) deionized water; (b) deionized water containing 25 ppm lithium added as LiCl; and (c) deionized water containing 100 ppm lithium added as LiCl. After 4 weeks on this regimen the dogs were evaluated for plaque and gingivitis and no significant differences in plaque and gingivitis were found between the groups. Possible toxic manifestations were observed, so that for the third group (receiving 100 ppm) the experiment was terminated midway. Oral Health Research Institute, Indiana University School of Dentistry, 410 Beatty Avenue, Indianapolis, Ind 46202. Dr. Philip Pack Effect
of
Experimental Neutropenia on Oral Wound Healing in Guinea Pigs
Andersen, L., Attström, R., and Fejerskov, O. Scand J Dent Res 86: 237, July, 1978. The effect of experimental neutropenia on the oral wound healing process was studied in 16 guinea pigs while corresponding wounds in 15 normal animals were used as controls. Daily injections of heterologous anti-neutrophil serum were given to induce neutropenia and thus reduce circulating neutrophils. Biopsies of palatal mucosa were taken 6, 24, 48, and 120 hours after wounding. Animals treated with antiserum had a distinct decrease in the number of neutrophils in the wound
cavities while the number of mononuclear cells remained the same in both the neutropenia and control wounds. Bacterial invasion was much deeper in the neutroperiic wounds but the rate of re-epithelialization was the same in both groups. It was concluded that neutrophils are the principal agents for host defense and indirectly determine the direction and level of epithelial cell migration. Department of Oral Pathology,
Royal Dental College, Vennelyst Boulevard, DK-8000, Aarhus, C, DenDr. Philip Pack mark. of 12 Year Old Inner-City Children Relationship to Oral Health
Snack Food Consumption and its
Clancy, K. L., Goldberg, H. J. V., and Ritz, A. J Public Health Dent 38: 227, Summer, 1978. Dental examinations were performed on 92 12-year-old children from three inner-city schools. The group was divided into 48 females and 44 males who were either black or had a Spanish surname. The presence or absence of both oral debris and gingivitis were tabulated by using a disclosing solution, the Gingival Index, and the Greene and Vermillion Oral Hygiene Index. Relationships between frequency of consumption of 18 common snack foods, sex variables, and oral health scores were noted. Although only few relevant relationships between intake of snack foods and overall oral health could be demonstrated, it was found that both black male and female children had substantially higher levels of gingivitis, decayed teeth and oral debris than the other children studied. Reported frequency of eating cake and cupcakes was shown to be correlated with total oral debris and gingivitis. Consumption of chewy candy and ice cream had a definite positive correlation with total DMF scores. A problem related to this type of study is the unknown actual sucrose content of many snack foods. Department of Dental Research, University of Rochester School of Medicine and DenDr. Walter Sepura tistry, Rochester, NY 14642.
