Increased systemic levels of inflammatory mediators following one-stage full-mouth scaling and root planing.

BACKGROUND AND OBJECTIVE: Full-mouth scaling and root planing (FM-SRP) acts as a potent inflammatory stimulus immediately after treatment; however, systemic inflammation typically improves in the long term. The contribution of FM-SRP to systemic biological and acute-phase responses is largely unknown. The purpose of this prospective intervention study was to assess the systemic and local biological responses after FM-SRP. MATERIAL AND METHODS: Thirty-one patients with generalized moderate-to-severe chronic periodontitis received 1-stage FM-SRP. Measurement of clinical parameters and body temperature as well as collection of subgingival plaque, peripheral blood and gingival crevicular fluid was performed before and after treatment 2 or 3 times. Quantification of periodontopathic bacteria in the sulcus and measurement of corresponding serum IgG titers were performed. Systemic and local inflammatory markers such as endotoxin, high-sensitive C-reactive protein (hs-CRP) and 6 inflammatory cytokines were assessed using high-sensitivity assays. RESULTS: Compared to baseline values, FM-SRP resulted in a substantial improvement in clinical parameters (P < .05), lower bacterial counts (P < .01) and a significant decrease of IgG titers against Porphyromonas gingivalis (P < .001) 6 weeks after treatment. Comparing baseline parameters to those at 1 day post-treatment, there was a statistically significant elevation in body temperature (P = .007). In addition, a 5-fold increase in hs-CRP (P < .001), a remarkable increase in interferon-γ (P < .001) and a slight increase in interleukin (IL)-12p70 (P = .001) were detected in serum samples. In the gingival crevicular fluid, marked increases in hs-CRP (P < .001), IL-5 (P = .001), IL-6, IL-12p70 and tumor necrosis factor-α (P < .001 for the latter 3 markers) were noted 1 day after treatment. Endotoxin levels were below measurable limits for most time points. CONCLUSION: FM-SRP resulted in clinical and microbiological improvement 6 weeks post-treatment, but produced a moderate systemic acute-phase response including elevated inflammatory mediators 1 day post-treatment.

Biodegradable gelatin/beta-tricalcium phosphate sponges incorporating recombinant human fibroblast growth factor-2 for treatment of recession-type defects: A split-mouth study in dogs.

BACKGROUND AND OBJECTIVE: Tissue engineering by using recombinant human (rh) growth factor technology may offer a promising therapeutic approach for treatment of gingival recession. Fibroblast growth factor-2 (FGF-2) has shown the ability to promote periodontal regeneration. Gelatin/beta-tricalcium phosphate (gelatin/ß-TCP) sponges have been developed to control the release of growth factors. The present study evaluated the periodontal regenerative efficacy of rhFGF-2 by comparing gelatin/ß-TCP sponges incorporated with rhFGF-2 to the scaffolds alone in artificially created recession-type defects in dogs. MATERIAL AND METHODS: Critically sized buccal gingival recession defects were surgically created on maxillary canine teeth of five dogs. In each animal, defects were randomized to receive either a gelatin/ß-TCP sponge soaked with rhFGF-2 (gelatin/ß-TCP/rhFGF-2) or phosphate-buffered saline (gelatin/ß-TCP). Eight weeks after surgery, biopsy specimens were obtained and subjected to microcomputed tomography and histological analyses. RESULTS: Complete root coverage was achieved in both groups. Microcomputed tomography revealed significantly greater new bone volume in the gelatin/ß-TCP/rhFGF-2 group. Histologically, both groups achieved periodontal regeneration; however, gelatin/ß-TCP/rhFGF-2 sites exhibited more tissue regeneration, characterized by significantly larger amounts of new cementum and new bone. Gelatin/ß-TCP sites featured increased long junctional epithelium and connective tissue attachment. In the gelatin/ß-TCP/rhFGF-2 sites, new bone exhibited many haversian canals and circumferential lamellae as well as remarkably thick periosteum with blood vascularization and hypercellularity. CONCLUSION: Within the limitations of this study, rhFGF-2 in gelatin/ß-TCP sponges exhibits an increased potential to support periodontal wound healing/regeneration in canine recession-type defects.

Ridge augmentation using recombinant human fibroblast growth factor-2 with biodegradable gelatin sponges incorporating ß-tricalcium phosphate: a preclinical study in dogs.

BACKGROUND AND OBJECTIVE: Fibroblast growth factor-2 (FGF-2) regulates the proliferation and differentiation of osteogenic cells, resulting in the promotion of bone formation. Biodegradable gelatin sponges incorporating ß-tricalcium phosphate (ß-TCP) have been reported as a scaffold, which has the ability to control growth factor release, offering sufficient mechanical strength and efficient migration of mesenchymal cells. In this study, we evaluated the effects of the combined use of recombinant human FGF-2 (rhFGF-2) and gelatin/ß-TCP sponge on ridge augmentation in dogs. MATERIAL AND METHODS: Six male beagle dogs were used in this study. Twelve wk after tooth extraction, bilateral 10 × 5 mm (width × depth) saddle-type defects were created 3 mm apart from the mesial side of the maxillary canine. At the experimental sites, the defects were filled with gelatin/ß-TCP sponge infiltrated with 0.3% rhFGF-2, whereas gelatin/ß-TCP sponge infiltrated with saline was applied to the control sites. Eight wk after surgery, qualitative and quantitative analyses were performed. RESULTS: There were no signs of clinical inflammation at 8 wk after surgery. Histometric measurements revealed that new bone height at the experimental sites (2.98 ± 0.65 mm) was significantly greater than that at the control sites (1.56 ± 0.66 mm; p = 0.004). The total tissue height was greater at the experimental sites (6.62 ± 0.66 mm) than that at the control sites (5.95 ± 0.74 mm), although there was no statistical significant difference (p = 0.051). Cast model measurements revealed that the residual defect height at the experimental sites (2.31 ± 0.50 mm) was significantly smaller than that at the control sites (3.51 ± 0.78 mm; p = 0.012). CONCLUSION: The combined use of rhFGF-2 and gelatin/ß-TCP sponge promotes ridge augmentation in canine saddle-type bone defects.

Effect of a tunnel-structured ß-tricalcium phosphate graft material on periodontal regeneration: a pilot study in a canine one-wall intrabony defect model.

BACKGROUND AND OBJECTIVE: Tissue regeneration is affected by the porosity, chemical properties and geometric structure of graft materials. Regeneration of severe periodontal defects, such as one-wall intrabony defects, is difficult because of reduced tissue support, and bone grafts are commonly used in such cases. In the present study, a tunnel-structured ß-tricalcium phosphate (tunnel ß-TCP) graft material designed to stimulate bone formation was fabricated. The objective of this pilot study was to evaluate the effect of this graft material on periodontal regeneration in one-wall intrabony defects in dogs. MATERIAL AND METHODS: Six male beagle dogs were used in this study. First, the mandibular second and third incisors were extracted. Experimental surgery was performed 12 wk after tooth extraction. Bilateral 4 × 8 mm (width × depth) one-wall intrabony defects were created in the mesial side of the mandibular canines. At the experimental sites, the defects were filled with tunnel ß-TCP, whereas the control defects were left empty. Twelve weeks after surgery, qualitative and quantitative histological analyses were performed. RESULTS: There were no signs of clinical inflammation 12 wk after surgery. Coronal extension indicative of new bone formation was higher at the experimental sites than at the control sites, although the differences between both the sites in the newly formed cementum and connective tissue attachment were not significant. Newly formed periodontal ligament and cementum-like tissue were evident along the root surface at the experimental sites. The inner surface of the tunnels was partially resorbed and replaced with new bone. New blood vessels were observed inside the lumens of tunnel ß-TCP. CONCLUSION: Tunnel ß-TCP serves as a scaffold for new bone formation in one-wall intrabony defects.

Pocket epithelium in the pathological setting for HMGB1 release.

High-mobility group box-1 (HMGB1) protein acts as a transcription factor in the nucleus and also as a pro-inflammatory cytokine when released into extracellular fluids. The presence of higher levels of HMGB1 is reported in the gingival crevicular fluid from periodontal patients. Since the proliferation of bacteria within the periodontal pocket is closely involved in the exacerbation of periodontal disease, it is hypothesized that the periodontal pocket causes the release of HMGB1. Immunohistochemical staining of inflamed gingiva revealed that HMGB1 is exclusively dislocated from the nucleus to the cytoplasm in the pocket epithelium, whereas it is mainly present in the nucleus in the gingival epithelium. Butyric acid, an extracellular metabolite from periodontopathic bacteria populating the periodontal pocket, induced the passive release of HMGB1 as a result of eliciting necrosis in the human gingival epithelial cell line. Thus, the periodontal epithelium may provide a unique pathological setting for HMGB1 release by bacterial insult.

Histological evaluation of alveolar ridge augmentation using injectable calcium phosphate bone cement in dogs.

Alveolar ridge augmentation is an important procedure to restore tooth loss. Several types of graft materials have been used for augmenting the alveolar ridge. An injectable calcium phosphate cement (CPC) has been applied to periodontal bone defects and has shown favourable results. Thus, this CPC may work as an effective graft material for alveolar ridge augmentation. The aim of this study was to evaluate the effectiveness of the CPC for large-scaled (about 7 x 8 x 6 mm) ridge augmentation in dogs. Alveolar ridge defects were created bilaterally in the maxilla of six beagle dogs. The CPC was applied to one of the bilateral maxillary defects. The untreated defect on the contralateral side served as control. The animals were sacrificed at 6 months after surgery and decalcified histological specimens of the alveolar ridge were prepared histometrically and evaluated under a light microscope. Newly formed and reconstructed alveolar ridges covering the CPC were observed in all experimental sites. In the control sites, only slight newly bone formation was observed. Histomorphometrical analysis indicated that the CPC grafted group exhibited significantly (P = 0.0001) increased area and height in new bone formation compared with those of the control group. The results indicate that the CPC appears to be an effective material for alveolar ridge augmentation and may act as a space maintainer to conduct new bone formation.

Effect of rhBMP-2 with PLGA/gelatin sponge type (PGS) carrier on alveolar ridge augmentation in dogs.

Recombinant human bone morphogenetic protein-2 has been shown to promote bone formation because of its osteoinductive property. The purpose of this study was to evaluate the efficacy of rhBMP-2 delivered on a poly (D, L-lactic-co-glycolic acid) copolymer/gelatin sponge (PGS) in vertical alveolar ridge augmentation on height-reduced edentulous mandible to verify the retention of rhBMP-2 withstanding the pressure of soft tissues. Coronal defects of the alveolar bone were created in six adult beagle dogs. After a healing period of 9 weeks, PGSs with or without rhBMP-2 (0 or 0.4 mg mL(-1)) were implanted on the defects(6 mm in height, 30 mm in length, 8 mm in width). Sixteen weeks after implantation, the bone mineral content (BMC) and the total bone area were measured by peripheral quantitative computed tomography. The BMC and the total bone area of the defect sites with rhBMP-2 group were significantly greater (133+/-33 mg mm(-1), 277+/-54 mm2, respectively) than those of the control group (80+/-19 mg mm(-1), 155+/-49 mm2, respectively) (P<0.01, P<0.0001, respectively; paired t-test). From the histological analyses, the height of newly formed bone in the experimental group was greater than that of the control group (4.3+/-0.9 mm, 0.22+/-0.28 mm, P<0.0001, n=6, paired t-test). These results indicate that PGS has characteristics of effective bone graft substitutes for implantation of rhBMP-2 on vertical alveolar ridge augmentation in huge defect of mandibles in dogs.

Distraction osteogenesis for craniosynostosis.

OBJECT: The authors describe the use of distraction devices and surgical techniques of distraction osteogenesis for the treatment of patients with craniosynostosis. METHODS: Since 1994, the authors have performed distraction procedures in 23 patients with craniosynostosis in whom osteogenesis was achieved. Thirteen of the 23 patients underwent a complete Le Fort III midface osteotomy and distraction. In 10 patients the distraction osteogenesis involved the cranial bone; six underwent combined forehead and midface distraction (Le Fort IV distraction) in which multiple internal devices were used after performing a Le Fort IV osteotomy. An external distraction procedure was used to treat the first two cases. Since 1996, the authors have used internal devices developed in their unit. Distraction was initiated 1 week after the osteotomy at the rate of 0.5 mm per day for the cranium and 1.0 mm per day for the midface. The consolidation phase after distraction was initiated was 2 to 3 months. No major complications such as intracranial infection or neurological deficits were observed during the course of distraction osteogenesis. The osteogenesis generated at the distraction site was considerably satisfactory; and recurrence of the deformity in the follow-up period was minimal. CONCLUSIONS: Distraction osteogenesis for craniofacial deformity has numerous advantages: 1) bone grafting is unnecessary; 2) the procedure is less invasive, has short operating time, and less blood loss occurs than in conventional craniofacial procedures; 3) no intracranial dead space is created; 4) there is a good amount of blood flow to the bone segment; and 5) soft-tissue expansion occurs. The authors believe that distraction osteogenesis is a versatile and stable option for the treatment of patients with craniosynostosis.

Histological examination of regenerated bone through craniofacial bone distraction in clinical studies.

The process of bone formation by distraction osteogenesis of the craniofacial bone has been studied in animals. To our knowledge there are no published findings in which histological examination of craniofacial distraction in humans has been reported. Specimens were obtained from 10 patients who underwent craniofacial distraction: 2 patients who underwent mandibular distraction, 7 patients who underwent midface distraction, and 1 patient who underwent nasal bone distraction. These specimens were examined histologically. The results revealed that 8 of 10 patients exhibited new bone formation. No cartilaginous callus formation was observed in any of the specimens, which strongly suggests that new bone was produced by intramembranous ossification during human craniofacial bone distraction.

Vertical symphyseal osteotomy.

For the treatment of mild crossbite with increased bigonial distance, the authors performed a vertical symphyseal osteotomy on six patients in the last 3 years. Three of these patients had cleft lip deformities and the others had operations for orthodontic or aesthetic reasons. After exposing the mandible through the buccal mucosal incision, both premolars were extracted with or without conventional segmental osteotomy. The two vertical symphyseal osteotomies were performed with approximately 1 cm between them, and the central part of the mandibular bone was discarded. The bilateral segments of the mandibular body were fixed in the midline using titanium miniplates. Satisfactory results were obtained with a reduction in the size of the mandibular arch, which produced better three-dimensional proportions in the bimaxillary area. No patients had temporomandibular joint problems, however postoperative orthodontics were essential for this type of operation.

Avoiding ectropion by using the Mitek Anchor System for flap fixation to the facial bones.

The application of the Mitek Anchor System for bony fixation of the flap in the cheek area is described. The cervicofacial rotation-advancement flap is fixated to the malar bone using Mini Anchors for the purpose of diminishing the downward traction on the lower eyelid. They reduced the tension in the distal part of the flap and avoided distal-edge necrosis and ectropion. In another patient the free vascularized musculocutaneous flap, which had been grafted previously for a surgical defect in the cheek and resulted in ectropion of the lower eyelid, was fixated to the malar bone, and the ectropion was corrected. The Mitek Anchor System is useful in flap fixation to the bone because it provides a simple, fast, and reliable method for flap fixation with minimal dissection and precise placement.

Medical canthoplasty with the Mitek Anchor System.

A variety of surgical techniques have been described for medial canthal tendon reattachment. They generally require technical skill and prolonged operating time. We have applied a new device, the Mitek Anchor System, in reattaching the medial canthal tendon to the medial orbital wall in 3 patients, and got excellent tendon fixation with this rapid and simple method. No complications, such as local infection or exposure, have occurred in any of the patients up to the present. Medial canthoplasty using the Mitek Anchor System has the advantage of being an easy technique with very accurate placement of the anchor and, consequently, reduced operating time. The operation can be performed through a small incision as well, and may not be so invasive as with other conventional procedures. This new technique of medial canthoplasty offers an excellent alternative to conventional techniques.

Combined use of an orbital osteotomy and living bone graft in the treatment of huge ossifying tumors involving the orbit.

Huge ossifying tumors involving the orbit were treated with a combination of craniofacial surgery and microsurgical techniques in two patients. The orbital osteotomy facilitated wide exposure of the tumors and their excision even though the tumors were extremely large. Stable results were obtained in one stage without visual disturbance by simultaneous reconstruction of the resulting bony defects using a free vascularized bone graft even in unfavorable tissue beds such as when one side of the bone graft is exposed to the affected nasal cavity or maxillary sinus. The combination of craniofacial surgery and microsurgical techniques has proven in our experience to be an effective approach to the treatment of a huge orbital ossifying tumor in one stage.

A thinned forearm flap transfer to the nose.

We employed a forearm flap that had been thinned through primary defatting for nasal covering in three cases to reduce the need for secondary revision. Partial flap loss did occur in one case due to subcutaneous vascular plexus injury, but acceptable results were obtained in the remaining two cases. Donor site concave deformities were substantially reduced by removal of fat from around the flap margin. Great care must be taken during surgery to avoid damage to the small vascular network around the pedicle to prevent flap necrosis.

Harvest of sural nerve grafts using the endoscope.

Endoscopic surgical techniques were employed in 5 patients to harvest the sural nerve atraumatically with a minimal number of skin incisions. The medial sural nerve was harvested by two 2-cm-wide transverse incisions made under endoscopic-magnified visualization, which allowed the surgeon to see the detailed structure of the nerve and surrounding tissue. This method requires minimal traction of the nerve during nerve dissection, and postoperative pain and swelling were less than encountered with conventional methods, because the method we have employed is less invasive and atraumatic.

Extremely thinned inferior rectus abdominis free flap.

To overcome a major drawback of the inferior rectus abdominis free flap, unpleasant thickness in a obese patient, a method of extreme thinning of the flap has been introduced. Extreme thinning is achieved by resecting a large volume of subcutaneous fatty tissue of the flap using scissors without damaging the subdermal vascular plexus. According to our clinical experience, it is supposed that the extremely thinned portion can be prepared safely when the width-to-length ratio is within 1:2.

A long surviving case of holoprosencephaly agnathia series.

The rare syndrome of the agnathia with microstomia, aglossia, synotia (the external ears approaching one another in the midline) and brain malformation (agnathia-holoprosencephaly) was reported by Pauli et al. (1983) as a developmental field defect. This syndrome has two subgroups. One is more severe with brain malformation (holoprosencephaly), and the other is less severe without brain malformation. This report presents a long surviving case of this syndrome without brain malformation.