Long Term Observations and Results on the Treatment of Alveolar Bone Defects

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EDITORIAL

Zbigniew Jańczuk

1

_{, Elżbieta Dembowska}

2

_{, Małgorzata Mazurek-Mochol}

2

_,

Konrad Seńko

3

Long Term Observations and Results

on the Treatment of Alveolar Bone Defects

Długoletnie obserwacje i wyniki leczenia ubytków kostnych przyzębia

1_{Department of Child Dentistry, Pomeranian Medical University in Szczecin, Poland} 2_{Department of Periodontology, Pomeranian Medical University in Szczecin, Poland} 3_{Department of Dental Prosthetics, Pomeranian Medical University in Szczecin, Poland}

Abstract

Objectives. This paper presents the results of treatment for osseous defects in the alveolar bone selected patients

over 40 years of age who were diagnosed with advanced periodontitis.

Material and Methods. All three patients were treated with a regenerative surgical procedure using a range of

biomaterials: enamel matrix derivative, hydroxyapatite and tri-calcium phosphate.

Results. Over a period 6- to 9-years, no complications were observed. Digital radiography was used to evaluate the

good treatment results, with the outcome confirming the clinical results.

Conclusions. Analysing radiograms by recording and comparing the level of grey hue at selected points indicates

improved density in the structures under evaluation, which can be treated like the expected result of bone regenera-tion following surgical treatment with bonelike grafts and connective tissue graft (Dent. Med. Probl. 2010, 47, 3,

273–282).

Key words: periodontitis, infrabony defects, surgical treatment, regenerative periodontal therapy, digital radiology.

Streszczenie

Cel pracy. W pracy przedstawiono wyniki leczenia ubytków kostnych wyrostka zębodołowego wybranych

pacjen-tów po 40. r.ż. z rozpoznanym zaawansowanym zapaleniem przyzębia.

Materiał i metody. Wszyscy pacjenci byli leczeni chirurgicznie. W trzech przypadkach wykonano chirurgiczne

zabiegi regeneracyjne z zastosowaniem różnych biomateriałów: pochodnych matrycy szkliwa, hydroksyapatytu i fosforanu beta-trójwapniowego.

Wyniki. Podczas 6–9-letniej obserwacji nie nastąpiło żadne powikłanie. Zastosowana do oceny wyników

radiogra-fia cyfrowa potwierdziła dobre wyniki kliniczne leczonych pacjentów.

Wnioski. Analiza radiogramów przez odnotowanie i porównanie poziomów szarości w zaznaczonych punktach

wskazuje poprawę gęstości ocenianych struktur, co można uznać za prawidłowy wynik regeneracji kości po lecze-niu chirurgicznym z zastosowaniem wszczepów kostnopodobnych i przeszczepu łącznotkankowego (Dent. Med.

Probl. 2010, 47, 3, 273–282).

Słowa kluczowe: zapalenie przyzębia, ubytki kostne, leczenie chirurgiczne, procedury regeneracyjne, radiologia

cyfrowa.

Dent. Med. Probl. 2010, 47, 3, 273–282

ISSN 1644-387X © Copyright by Wroclaw Medical University and Polish Dental Society

The development of periodontal surgery in periodontal tissue regeneration, along with tech-nological advances made using biomaterials, has created new approaches to the treatment of verti-cal, so-called angular bone loss in destructive pe-riodontitis. The aim of the surgery is a regenera-tion (restitutio ad integrum) defined as the

recon-struction of lost tissue along with the restoration of their structure and function [1–4].

In recent decades, a wide range of treatment methods have been implemented with the aim of regenerating perodontal tissue. These methods differ in technique, biomodification of the root cement surface, implementation of different graft

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and bone or biomaterial graft types, and in bar-rier membrane application. The grafts and bone or biomaterial grafts facilitate the alveolar bone, parodontium, and root cement reconstruction by osteogenesis, osteoinduction, or osteoconduction. According to current knowledge, using autogenous bone and bone-substitute materials leads to better clinical results expressed as shallower periodontal pockets and increased attachment level gain.

The most common radiological examination for perodontium appraisal are intraoral roentge-nograms, which have the greatest imaging ac-curacy with regard to anatomical details of the perodontium [5–10]. Currently, radiography and digital radiovisiography are increasingly used in dentistry, since they allow radiodensitometric me-asurement, which has the advantage over conven-tional radiography of being able to detect changes caused by relatively low levels of demineralization of bone tissue [11–16].

Digora® software allows the application of digital tomosynthesis in picture assessment, i.e. marking pixels with the same greyness scale or optical density in one colour, a result of which is that the colour on the monitor can be assigned to tissues with the same optical density. A digital pic-ture can also be obtained by digitalizing a conven-tional image.

Material and Methods

Results

The material for the radiological examinations were bone defects in the parodontium that had been surgically treated using different methods. The ef-fectiveness of treatment was assessed by examining the density of the bone defect structures (created during the periodontitis) during the healing pro-cess after surgery. In order to assess the density of rebuilt structures in the bone cavities, lines were drawn in selected areas resulting in a density histo-gram of the points designated by the lines. Based on the density histogram of the structures under ex-amination, points on every line were defined. These points were drawn in the same places on the im-ages from each examination period. Examinations occurred every year or every several years (for up to 9 years following surgery). Several images were available for each of the three patients. For diagno-sis simplification, only three representative images per patient are presented in this paper.

Case 1

A male patient, 46 years of age, came to the De-partment of Periodontology in 2000 with looseness

of the right maxillary central incisor. The X-ray showed that the bone pocket reached far down to the root apex, and connected with a periapical le-sion. An 8-mm periodontal pocket was observed, and there was no reaction of the dental pulp to the vitality tests. During endodontic treatment, necrosis of the pulp in the chamber and canal of the right maxillary central incisor was found. The treatment was completed with gutta-percha canal filling (Fig. 1). A frenulectomy with infiltration anaesthesia and a bone defect opening was car-ried out in February 2001, performing flap sur-gery with the removal of granular tissue up to the right maxillary central incisor root apex. Enamel matrix derivative (Emdogain®) was applied after scaling and polishing of the root surface, and the bone defect was filled with hydroxyapatite (HA) and tn-calcium phosphate (βTCP). Figure 2 shows the regeneration of the bone defect observed in 2007. Figure 3 shows bone density increase in the area of biomaterial application, followed by a slight decrease later. The fact that the periapical lesion and bone defect were filled with bone-like tissue should be taken into consideration. The periodon-tal pocket decreased to 3 mm after only one year. The assessed roentgenograms showed that the bone density increased from 5 (point A) to 16 grey units (point D) (Fig. 3 and Table 1).

Case 2

A 57-year-old female patient reported loose-ness and pain in the mandibular incisors in 2000. She was an insulin-dependent diabetic and smoked about 15 cigarettes per day. The maxilla was eden-tulous, and there were no molars in the mandible. The patient had lost her teeth partly because of caries and partly because of periodontal disease. The X-ray showed mandibular alveolar bone loss extending into the root apex of three incisors. After scaling, significant looseness in 3 incisors was found which had to be fixed, the pulp extir-pated, and the canals filled. In addition, surgery was carried out in 2000, which consisted of expos-ing the flap, removexpos-ing granulation from the bone defect, scaling and polishing of the root surface, and grafting HA with flap suturing. Over the next 9 years, the patient supervision included scaling with root surface polishing twice a year.

Two vertical lines were drawn on the control radiograms (Fig. 4, 5) in the interdental sections of the right mandibular lateral and central inci-sors, also on the right and left mandibular central incisors. Every line was marked with three density measurement points; A, B, and C and D, E, and F. Over the 9-year observation period, the values recorded showed an increase in bone density.

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Fi-gures 6 and 7 show the results. In 2009, the incre-ase in greyness was as high as 35 units at point B (Fig. 6 and Table 2) and 12 units at point C. At point E (Fig. 7 and Table 3), the increase was 32 units. The patient almost entirely gave up smoking (2–3 cigarettes per day).

Case 3

In 2001, a 47-year-old male patient presented with periodontitis within the mandibular incisors, particularly near the right mandibular central and lateral incisors. The depth of the pocket near these teeth was 5 mm, and the bottom of the pocket was

Fig. 1. Patient 1, roentgenogram before

sur-gical treatment

Ryc. 1. Pacjent 1, rentgenogram przed

lecze-niem chirurgicznym

Fig. 2. Patient 1, 7 years after regeneration

treatment

Ryc. 2. Pacjent 1, 7 lat po zabiegu

regenera-cyjnym

Fig. 3. Density change at four points assessed

on 3 consecutive roentgenograms in patient 1

Ryc. 3. Zmiany gęstości 4 punktów

oce-nianych na 3 kolejnych rentgenogramach u pacjenta 1

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in contact with the apical granuloma. These teeth were fixed in the mandible with only the apex be-cause, apart from the periodontal pocket, the root in the right mandibular lateral incisor was denu-dated by 12.5 mm. In 2002, after fixation, surgery with local anaesthesia was carried out, which in-volved covering the root in the right mandibular lateral incisor with two grown lateral flaps moved concentrically and sutured on a free connective

tissue graft taken from the palate and positioned crosswise to the root with an Emdogain covering. As a result, the root denudation decreased from 12.5 mm to 8 mm (34%) with the periodontal pockets eliminated and the apical lesions healed. Three lines were drawn on the next radiograms; two in the interdental sections of the right man-dibular central and lateral incisors, and also right and left mandibular central incisors. One line was

Table 1. Density measurements at 4 (A, B, C, D) points assessed on 3 consecutive roentgenograms in patient 1 Tabela 1. Pomiary gęstości 4 (A, B, C, D) ocenianych punktów na kolejnych 3 rentgenogramach u pacjenta 1

Points on the line

(Punkty na linii) Exam. 1/Fig. 1 (Bad. 1/ryc. 1) Exam. 2 (Bad. 2) Exam. 3/Fig. 2 (Bad. 3/ryc. 2) Greyness increase between examinations 1–3 (Przyrost szarości między badaniami 1–3)

A 60 75 65 5

B 51 70 60 9

C 42 66 50 8

D 42 60 58 16

Fig. 4. Patient 2, X-ray before surgical

treat-ment

Ryc. 4. Pacjentka 2, RTG przed leczeniem

chirurgicznym

Fig. 5. Patient 2, 9 years after treatment Ryc. 5. Pacjentka 2, po 9 latach od zabiegu

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Fig. 6. Density change at three points

assessed on 6 consecutive roentgeno-grams in patient 2

ocenianych na kolejnych 6 rentgeno-gramach u pacjentki 2 0 20 40 60 80 100 exam. 1/Fig. 1

bad. 1/ryc. 1 exam. 2bad. 2 exam. 3/Fig. 2bad. 3/ryc. 2

A B C D de ns ity / g re yn es s

Table 2. Density measurement at 3 points (A, B, C) assessed on 6 consecutive radiograms in patient 2 Tabela 2. Pomiary gęstości 3 ocenianych punktów (A, B, C) na kolejnych 6 radiogramach u pacjentki 2

Points on the line (Punkty na linii) Exam. 1/ Fig. 3 (Bad. 1/ ryc. 3) Exam. 2

(Bad. 2) Exam. 3 (Bad. 3) Exam. 4 (Bad. 4) Exam. 5 (Bad. 5) Exam. 6/Fig. 4 (Bad. 6/ ryc. 4)

Greyness increase between ex-aminations 1–6

(Przyrost szarości między bada-niami 1–6)

A 29 46 20 19 19 21 –8

B 37 59 59 68 69 72 35

C 61 78 66 75 65 73 12

Fig. 7. Density change at three

points assessed on 6 consecutive roentgenograms in patient 2

ocenianych na kolejnych 6 rentgeno-gramach u pacjentki 2 0 20 40 60 80 100 120 1 2 3 4 5 6 exam. bad. de ns ity / gr ey ne ss A B C

Table 3. Density measurement at 3 points (D, E, F) assessed on the 6 consecutive radiograms in patient 2 Tabela 3. Pomiary gęstości 3 ocenianych punktów (D, E, F) na kolejnych 6 radiogramach u pacjentki 2

(Bad. 2) Exam. 3 (Bad. 3) Exam. 4 (Bad. 4) Exam. 5 (Bad. 5) Exam. 6/Fig. 4 (Bad. 6/ ryc. 4)

Greyness increase between ex-aminations 1–6

(Przyrost szarości między bada-niami 1–6)

D 31 50 16 15 19 20 –11

E 42 74 60 72 69 74 32

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drawn perpendicular to the others across the api-cal lesions of these teeth. Every line was marked with two density measurement points. Bone den-sity after 7 years had increased by 20 units at po-int A (Fig. 8 and Table 4) and by 15 units of grey-ness at point B. The increase was 27 units at point C (Fig. 9 and Table 5), and 4 units at point D. At points E and F, the increase was 18 units (Fig. 10 and Table 6).

Discussion

Table 7 compares the data from the three ca-ses, which involved both chronic and aggressive periodontitis. The three cases were individuals over 40 years of age who were observed over a 6- to 9-year period, treated differently depending on the clinical review, disease progression, and ava-ilability of therapeutics. One case of aggressive periodontitis was accompanied by type 1 diabetes and smoking (approximately 1 pack per day).

The primary treatment method for tooth bone defects is periodontal tissue regeneration, most often with osseous and bone-substitute materials [17, 18]. Most researchers, however, shows that the application of these materials alone results in the formation of a long epithelial attachment within the alveolar pocket because periodontal

regenera-tion under clinical condiregenera-tions is possible with the application of barrier membranes or enamel ma-trix proteins. The three tissues are reconstructed, creating clinical attachment, bone, and periodon-tal ligament [17].

The authors did not perform histological ex-aminations because these were impossible to carry out under our operating conditions. Therefore, the authors assume that, in most of the cases, bone-like tissue could form, especially after hydroxyapatite application alone (patient 2). The clinical results of these treatments after 6–9 years indicate that they are effective, although they do not always result in the desired periodontal regeneration.

Among alloplastic grafts, the most interest-ing seem to be tricalcium phosphates, particu-larly β-TPC. Its degradation takes place between 9 months and 4 years because of hydrolysis and phagocytosis [17]. It is an osteoconductive, re-sorbable material, which resolves up to 50% af-ter one year. The size of the particles varies from 50 μm to 1000 μm, and the total porosity is 90%. There is a significant increase in the attachment and filling of this material after implantation in-to periodontal defects [19, 20]. This may be con-firmed in these cases, as can the efficacy of the enamel matrix proteins, which applied together with β-TPC result in a significant regeneration of osseous tissue [21, 22]. Our results, which

includ-Fig. 8. Density change at 2 points

(A, B) assessed on 5 consecutive roentgenograms in patient 3

(A, B) ocenianych na kolejnych 5 rentgenogramach u pacjenta 3 0 20 40 60 80 100 120 1 2 3 4 5 6 exam. bad. de ns ity / gr ey ne ss D E F

Table 4. Density measurement at 2 points (A, B) assessed on the 5 consecutive radiograms in patient 3 Tabela 4. Pomiary gęstości 2 ocenianych punktów (A, B) na kolejnych 5 radiogramach u pacjenta 3

(Bad. 2) Exam. 3 (Bad. 3) Exam. 4 (Bad. 4) Exam. 5/Fig. 6 (Bad. 5/ryc. 6) Greyness increase between ex-aminations 1–5 (Przyrost szarości między bada-niami 1–5)

A 28 26 44 48 48 20

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Fig. 9. Density change at 2 points

(C, D) assessed on 5 consecutive roentgenograms in patient 3

(C, D) ocenianych na kolejnych 5 rentgenogramach u pacjenta 3 0 40 80 1 2 3 4 5 exam. bad. de ns ity / gr ey ne ss A B 0 40 80 1 2 3 4 5 exam. bad. de ns ity / gr ey ne ss C D

Fig. 10. Density change at 2 points

(E, F) assessed on 5 consecutive roentgenograms in patient 3

Ryc. 10. Zmiany gęstości 2

punk-tów (E, F) ocenianych na kolejnych 5 rentgenogramach u pacjenta 3

Table 5. Density measurement at 2 points (C, D) assessed on 5 consecutive radiograms in patient 3 Tabela 5. Pomiary gęstości 2 ocenianych punktów (C, D) na kolejnych 5 radiogramach u pacjenta 3

(Bad. 2) Exam. 3 (Bad. 3) Exam. 4 (Bad. 4) Exam. 5/Fig. 6 (Bad. 5/ryc. 6) Greyness increase between examinations 1–5 (Przyrost szarości między bada-niami 1–5)

C 23 21 45 48 50 27

D 45 45 43 42 49 4

Table 6. Density measurement at 2 points (E, F) assessed on 5 consecutive radiograms in patient 3 Tabela 6. Pomiary gęstości 2 ocenianych punktów (E, F) na kolejnych 5 radiogramach u pacjenta 3

(Bad. 2) Exam. 3 (Bad. 3) Exam. 4 (Bad. 4) Exam. 5/Fig. 6 (Bad. 5/ryc. 6) Greyness increase between examinations 1–5 (Przyrost szarości między bada-niami 1–5)

E 28 24 47 49 46 18

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Fig. 11. Patient 3, before surgical

treatment

Ryc. 11. Pacjent 3 przed zabiegiem

chirurgicznym

Table 7. Comparison of the essential parameters of the patients Tabela 7. Porównanie istotnych parametrów dotyczących pacjentów

Gender

(Płeć) Age (Wiek) Diagnosis (Rozpoznanie) Systemic diseases, habits (Choroby ogólne, nawyki)

Treatment method

(Metoda leczenia) No. of observa-tion years (Lata ob-serwacji) Tissue greyness increase (Przyrost szarości tkanek) M 46 chronic

peri-odontitis – flap surgery, curet-tage, Emdogain, HA, βTCP 6 9–16 F 57 aggressive periodontitis, endo-perio type II diabetes type 1,

smoking flap surgery, curet-tage, HA 9 12–35

M 47 aggressive

periodontitis, endo-perio type III

– flap surgery,

curet-tage, connective tis-sue graft, Emdogain

7 15–27 0 40 80 1 2 3 4 5 exam. bad. de ns ity / gr ey ne ss E F

Fig. 12. Patient 3, 7 years after

sur-gery

Ryc. 12. Pacjentka 3 po 7 latach od

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ed a 6- to 9-year follow up period, showed that there were no complications over time, providing positive evidence of the efficacy of β-TPC as an implant material. The digital radiography used during the observation and to assess the results confirms the clinical outcome of the patients. The assessment by marking and comparing the levels of grey at specified points in the radio-gram indicate an improvement in the structure density, which can be considered an appropriate result of bone regeneration or bone-like tissue af-ter surgical treatment accompanied by bone-like and connective tissue grafts [6, 18]. Furthermore, the lines marked on every radiogram graphically define the histograms of structure greyness, and in every case indicated a change by an increased level of greyness. Radiological examinations confirm the results of clinical observation in de-scribed three patients.

The increase in greyness during the course of observation was different in the cases. In some pa-tients, it increased gradually (e.g. Tables 1 and 7), whereas in others it increased in leaps and bounds (e.g. Tables 8 and 9). This depended largely on the location selected for the control points.

Worth emphasising is the long post-treatment follow-up period (6 to 9 years) and very good re-sults seen by the greyness level on the roentgeno-grams. In contrast, many research papers refer to short term observations (e.g. Christgau [17]).

The cases of alveolar bone treatment presen-ted in this paper and assessed by radiodensitome-try are crucial for practicing periodontists. Not only is there increasing accessibility to digital ra-diography during surgery, but also great improve-ments in the surgical methods used to treat bone defects. The 9-year observations are very helpful for clinicians.

References

Konopka

[1] T.: Algorytmy kompleksowego leczenia zapaleń przyzębia. Czas Stomatol. 2001, 54, 362–371. Maeda S., Maeda Y., Ono Y., Nakamura K., Sasaki

[2] T.: Interdisciplinary treatment of patient with severe patho-logic tooth migration caused by localized aggressive periodontitis. Am. J. Orthod. Dentofac. Orthop. 2005, 127, 374–384.

Tonetti M.S., Lang N.P., Cortellini P., Suvan J.E., Adriaens P., Dubravec

[3] D.: Enamel matrix proteins in

the regenerative therapy of deep intrabony defects. A multicentre randomized controlled clinical trial. J. Clin. Periodontol. 2002, 29, 317–325.

Wikesjö U.M., Selving

[4] K.A.: Periodontal wound healing and regeneration. Periodontology 2000, 1999, 19, 21–39.

Ǻkesson L., Häkansson J., Roślin

[5] M.: Comparison of panoramic and intraoral radiography and pocket probing for the measurement of the marginal bone level. J. Clin. Periodontol. 1992, 19, 326–332.

Dembowska

[6] E.: Zależność między kompleksowym leczeniem periodontologicznym a leczeniem ortodontycznym u pacjentów z zaawansowanym przewlekłym i agresywnym zapaleniem przyzębia. Rozprawa habilitacyjna. Wyd. PAM, Szczecin 2008.

Kantor M.I., Slome B.

[7] A.: Efficacy of panoramic radiography in dental diagnosis and treatment planning. J. Dent. Res. 1999, 68, 810–812.

Piotrowska

[8] M.: Zastosowanie konwencjonalnych badań rentgenowskich i radiografii cyfrowej w obrazowaniu przebiegu zębów replantowanych. Magazyn Stomatol. 2004, 14, 9, 12–14.

Szymańska J.

[9] : Badania radiologiczne. Praktyczna Periodontologia kliniczna, Red. Jańczuk Z. Wyd. Kwintesencja, Warszawa 2004.

White S.C., Pharoach

[10] M.J.: Radiologia stomatologiczna. Red. Pol.: Różyło T.K., Wyd. Czelej, 2000. Bercz C., Schwarz

[11] P., Sonnabend E.: Untersuchungen des neuen Radiowizjografia. Dsch. Zahnärzt 1990, 45, 728–729.

Chai-U-Dom O., Ludlow J.B., Tyndall D.A., Webber R.L

[12] .: Detection of simulated periodontal bone gain by digital substraction radiography with tuned-aperture computed tomography. The effect of angular disparity. Dentomaxillofac. Radiol. 2001, 30, 92–97.

Hun-Szretter K., Markiewicz H., Czerwiński K.

[13] : Systemy cyfrowego obrazowania rentgenowskiego w radio-logii stomatologicznej – alternatywa konwencjonalnych zdjęć zewnątrzustnych zębowych. Czas. Stomatol. 1996, 49, 579–585.

Khocht A., Janal M., Harasty L., Chang K.M.:

[14] Comparison of direct digital and conventional intraoral radio-graphs dietecting alveolar bone loss. J. Am. Dent. Assoc. 2003, 134, 1468–1475.

Luostarinen T., Tammisalo T., Vähätalo K., Tammisalo

[15] E.: Comparison of intra-oral digital and film radiog-raphy for diagnosis of periapical bone lesion. Dentomaxillofac. Radiol. 1995, 24, 92–93.

Matthews-Brzozowska T., Mikulewicz

[16] M.: Badanie gęstości kości wyrostka zębodołowego w okolicy wszcze-pów za pomocą radiografii cyfrowej Digora – doniesienie wstępne. Stomat. Współcz. 2003, 14, 1, 33–36.

Christgau M

[17] .: Knochen-und Knochenersatzmaterialien. Welchen Stellenwert haben sie heute in der regenerati-ven Parodontitstherapie? Parodontologie 2009, 3, 237–257.

Lynch S.E.

[18] : Methods for evaluation of regenerative procedures. J. Periodontol. 1992, 63, 1085–1092. Baldock W.T., Hutchens L.H.jr., Mc Fall W.T.

[19] , Sinpson D.M.: An evaluation of tricalcium phosphate implants in human periodontal osseous defects of two patients. J. Periodontol. 1985, 56, 1–7.

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Snyder A.J., Levin M.P., Cutright D.

[20] E.: Alloplastic implants of tricalcium phosphate ceramic in human perio-dontal osseous defects. J. Periodontol. 1984, 55, 273–277.

Döri F., Anweiler N., Gerea I., Sculean

[21] A.: Clinical evaluation of an enamel matrix protein derivative combi-ned with either a natural bone mineral or beta-tricalcium phosphate. J. Periodontol. 2005, 76, 2236–2243. Froum S.J., Weinberg M.A., Rosenberg E., Tarnow D.:

[22] A comparative study utilizing open flap debridement with and without enamel matrix derivative in the treatment of periodontal infrabony defects: a 12-month re-entry study. J. Periodontol. 2001, 72, 25–34.

Address for correspondence:

Małgorzata Mazurek-Mochol Department of Periodontology Pomeranian Medical University Powstańców Wlkp. 72 70-111 Szczecin Poland E-mail: malgorzata.mazurek@poczta.onet.pl Received: 8.07.2010 Accepted: 20.09.2010

Praca wpłynęła do Redakcji: 8.07.2010 r. Zaakceptowano do druku: 20.09.2010 r.