|Year : 2020 | Volume
| Issue : 4 | Page : 232-235
Ideal tissue regeneration option following periapical surgery
Malti Tuli1, Alankrutha Gangasani2, Muqthadir Siddiqui Mohammed Abdul3, Manpreet Kaur1, Sunil Kumar Gulia4, Piyush Raj Dharmi5
1 Guru Nanak Dev Dental College and Research Institutes, Sunam, Punjab, India
2 Panineeya Mahavidyalaya Institute of Dental Sciences and Research Center, Hyderabad, Telangana, India
3 Department of Paediatric Dentistry, Ministry of Health, King Khaled Hospital, Riyadh, Saudi, Arabia
4 Department of Oral and Maxillofacial Surgeon, SGT University, Jhajjar, Haryana, India
5 Department of Oral and Maxillofacial Surgeon, Babu Banarasi Das College of Dental Sciences, Lucknow, Uttar Pradesh, India
|Date of Submission||13-May-2020|
|Date of Decision||16-May-2020|
|Date of Acceptance||19-May-2020|
|Date of Web Publication||30-Nov-2020|
Guru Nanak Dev Dental College and Research Institutes, Sunam, Punjab
Source of Support: None, Conflict of Interest: None
Optimal tissue regeneration in the periapical region is essential following a periapical surgery. Literature shows that augmenting the osseous defect with artificial bone substitutes, growth factors, or barrier membranes acts as critical factors influencing the healing following surgical intervention. For the regeneration of tissues following periapical surgery, an essential requisite is progenitor/stem cells. Few studies have shown that simple use of a membrane barrier and/or bone graft following surgery might not produce adequate tissue regeneration. Literature clearly shows that few substitutes are capable of generating progenitor/stem cells and induce the undifferentiated mesenchymal cells to differentiate. Hence, this review is intended to throw light on whether tissue regeneration with the aid of bone grafts coupled with a membrane barrier will suffice or is there a need for recruiting progenitor/stem cells.
Keywords: Allogenous bone grafts, apicoectomy, guided tissue regeneration
|How to cite this article:|
Tuli M, Gangasani A, Mohammed Abdul MS, Kaur M, Gulia SK, Dharmi PR. Ideal tissue regeneration option following periapical surgery. J Dent Res Rev 2020;7:232-5
|How to cite this URL:|
Tuli M, Gangasani A, Mohammed Abdul MS, Kaur M, Gulia SK, Dharmi PR. Ideal tissue regeneration option following periapical surgery. J Dent Res Rev [serial online] 2020 [cited 2022 Jun 28];7:232-5. Available from: https://www.jdrr.org/text.asp?2020/7/4/232/302047
| Introduction|| |
It is a familiar observation that an untreated nonvital tooth will ultimately lead to a periapical pathology that eventually causes osseous damage. Occasionally, a precisely performed endodontic treatment can result in failure as a result of intra- or extra-radicular microbial infection. This can lead to the formation of a periapical lesion as a result of an inflammatory response to bacterial infection within the root canal. Surgical intervention in the periapical region is aimed to enhance healing, in addition to removing the unhealthy tissues.
Periapical surgery not only gains access to remove the unhealthy periapical tissues but also cleans the radicular areas and contours the adjacent bone. However, few studies have suggested that the healing of the tissues by the newly formed tissue generally fails to totally fully restore the architecture of the preexistent bone., The concept of tissue regeneration has been introduced with an intention to improve the quality of healing. The kind of cells that repopulate the wound initially determines the quality of healing. It is believed that the epithelial cells generally migrate quickly and play a crucial role in the initial healing of the wound. Hence, it is hypothesized that the elimination of the epithelial cells from the wound would permit other cellular variants with retarded regenerative potential to gain access.
Previous studies have shown the use of either bone graft materials or incorporation of biologically active molecules, in addition to the placement of a mechanical barrier following periapical surgery to enhance tissue regeneration in the periapical tissues. However, no consensus has been drawn till date as to which is the ideal path to be preferred with regard to tissue regeneration in the periapical tissues following periapical surgery.
| Tissue Engineering|| |
Tissue engineering aims at functional restoration of impaired or damaged tissues due to pathology or trauma. Stem cells have the ability of self-renewal. When these cells divide, few daughter cells form cells that eventually become differentiated cells. Based on their ability to become different tissues, they are categorized into totipotent, pluripotent, and multipotent stem cells. A scaffold extracellular matrix should contain growth factors to aid stem cell proliferation and differentiation, leading to improved and faster tissue development. Growth factors are biological modulators which can stimulate cell proliferation and differentiation.
| Bone Grafts|| |
Periapical lesions that are small in size may heal satisfactorily with the aid of resident osteoblasts, periodontal ligament cells, and cementoblasts. However, lesions that are larger in size would require recruitment of stem cells and their differentiation into osteoblasts, cementoblasts, and periodontal ligament cells. Few studies in the past have advocated that if the size of the osseous defect is too large, insufficient osseous regeneration of the wound would occur and the defect will heal by fibrous connective tissue repair.
Numerous studies in the past have demonstrated a better outcome with regard to tissue healing following periapical surgery, with the aid of regenerative technique using bone graft compared to the same lesions without regenerative techniques., It is believed that a simple enucleation of the periapical cyst usually leaves a bony defect. Considering the fact that the maxilla demonstrates a relatively high regenerative capacity, optimal obliteration of this osseous defect in the presence of a background of an inflammatory reaction may be hindered. Inadequate or less optimal bone healing results when regenerative technique are not employed due to the invagination of overlying tissue into the osseous defect, preventing osteogenesis. According to Jansson et al., the survival rates of periapical surgery were found to be 68% in molars and 77% in single-rooted teeth over a 10-year period. This highlights the fact that augmentation with the aid of bone grafts is essential to facilitate optimal tissue healing in the periapical region following periapical surgery.
The main purpose of augmented bone graft is to act as a template for osteogenesis and slowly resorb to permit replacement by new bone. Bone grafts have either osteogenic, osteoinductive, or osteoconductive properties. Hydroxyapatite can be considered to be a very effective alloplastic material, particularly in large bone destruction caused by periradicular lesion where it can facilitate effective bone replacement in the later stages as well as can provide functional support to the tooth in the initial stages. A recent study evaluated bone regeneration in the periapical region using platelet-rich fibrin (PRF) and nanocrystalline hydroxyapatite with collagen in combination with PRF and their effects on healing and concluded that the combination of PRF and nanocrystalline hydroxyapatite with collagen produced a significantly faster bone regeneration and that conventional technique and PRF were less predictable with its healing response. An added advantage of nanostructured materials is the ability to have an extremely high number of molecules on the surface of the material.
| Biologically Active Molecules|| |
They are host modulating agents. Platelet-rich plasma (PRP) mimics the terminal stage of coagulation cascade in the form of a formation of fibrin clot. The therapeutic properties of PRP are attributed to the release of certain growth factors released through alpha granules., It enhances collagen synthesis and angiogenesis, resulting in increased early wound strength. The growth factors act both locally and systemically in a self-regulatory feedback system.
Few studies suggested that the use of a triple-antibiotic paste for canal disinfection along with PRF strengthens the effectiveness of sterilization in carious teeth, infected dentin, periapical lesions, and necrotic pulp. A study showed that PRF has the ability to multiply pulp cells in addition to enhancing the expression of osteoprotegerin and alkaline phosphatase activity.
In vitro studies have demonstrated that PRF has shown no cytotoxicity toward many cells including preadipocytes, dermal prekeratinocytes, osteoblasts, oral epithelial cells, dental pulp cells, periodontal ligament cells, and gingival fibroblasts. Recently, studies have demonstrated that the PRF membrane has a very significant slow sustained release of many key growth factors (GFs) for at least 1 week and up to 28 days, which means that PRF could release GF with its own biological scaffold for wound-healing process.
A recent study used PRF with tricalcium phosphate (TCP) bone graft for treating a periapical cyst and advocated that usage of PRF and TCP together would yield enhanced results than usage of biomaterials alone. A recent study on the revascularization of immature pulp apices concluded that PRF acts as a biological connector for neoangiogenesis and vascularization. This highlights the fact that augmentation with the aid of bone grafts coupled with biologically active molecules is essential to facilitate optimal tissue healing in the periapical region following periapical surgery.
| Barrier Membranes|| |
To prevent invading of the oral epithelium and gingival connective tissue into the osseous defect, it is advisable to use a mechanical barrier in the form of a membrane over an osseous defect. This would create an environment for the multiplying cells with osteogenic potential to repopulate the defect which would allow a more predictable osseous repair. Resorbable membranes are made as an alternative to nonresorbable membranes to avoid an additional surgery. Biologically resorbable membranes such as polylactic acid and polyglycolic acid are dissolved by proteolytic enzymes from the polymorphonuclear cells into lactic acid or glycolic acid and excreted through the kidney. Anin vitro study evaluated three commercially available collagen membranes and three nonresorbable polytetrafluoroethylene membranes and concluded that resorbable membranes are more suitable to stimulate cellular proliferation when compared to nonresorbable membranes.
Collagen membrane provides binding sites for migrating cells required for healing, resulting in an environment that promotes tissue regeneration following surgical intervention. Previous studies have shown that collagen barrier membrane employed with a bone graft significantly enhances the preservation of alveolar crest height and shape, probing pocket depth, attachment, defect depth, and gingival recession compared to resorbable membranes.
To prevent infection following surgery, bioactive molecules or anti-infective agents are incorporated in barrier membranes. Results obtained from these studies indicated that the membranes containing >5% metronidazole exhibited obvious antibacterial activity without any cytotoxic effects.
Amnion membrane is derived from the human placenta. It incorporates growth factors presenting anti-inflammatory and antimicrobial properties. The thickness of the amnion membrane is lesser than collagen membranes, which assists a proper adaption over the osseous defect., Amnion membrane facilitates proliferation of the endothelial cells and angiogenesis, in addition to the recruitment of mesenchymal progenitor cells assisting accelerated wound healing. A recent retrospective study analyzed the healing of teeth with apicomarginal defects treated with apical surgery and enamel matrix derivative (EMD). They concluded that if the root end filling can effectively block bacterial leakage from the root canals healing of apicomarginal defects occur providing the epithelial downgrowth along the denuded root surface can be prevented. With regard to this, EMD may be superior to other regenerative techniques since it has a cytostatic effect on the epithelial cells.
| Inference|| |
The application of graft materials in the form of hydroxyapatite, TCP, or xenograft alone would lead to the formation of fibrous encapsulation of the graft material and thereby interfere with the ideal healing in the periapical tissues following surgical intervention. It is believed that a blood clot plays a key role to stabilize the wound matrix in the event of wound healing. Platelet alpha granules of PRP act as a source of growth factors that facilitate cellular proliferation and bone formation. PRF facilitates the preservation of the integrity of the bone graft material by revascularizing the bone graft particles through neoangiogenesis., Once PRF starts resorbing slowly, it releases growth factors that maintain a viable field to enhance healing., In addition to this, placement of a barrier membrane over the augmented osseous defect can prevent the invagination of oral epithelium and gingival connective tissue into the osseous defect thereby enhancing the wound healing.
| Recent Advances|| |
Periapical surgery is sometimes challenging in terms of locating the root-end for resection. The length of resection of root-end may not be easy to control, particularly in the hands of an inexperienced surgeon. This problem can be overcome with the guide of a three-dimensional (3D)-printed template. Conventional periapical surgical may leave a large bone defect. With the aid of the 3D-printed template, the diameter of the lesion caused by surgery could be restricted to 3–4 mm, only slightly larger than the length of resection (3 mm). This minimal invasive surgical procedure maximally limits injury to osseous tissues. Less damage to osseous tissues results in less hemorrhage during surgery, less postoperative complications, shorter healing time, and better prognosis.
A recent study employed cone-beam computed tomography imaging, 3D printing technology, and 3D surgical guide designed with computer-aided software. A hollow trephine bur was used to perform the osteotomy, resection of the root, and enucleation of the lesion. The intact cortical plate was salvaged and used as a graft along with PRF acquired preoperatively from the patient's blood. The positioning guide allowed the clinicians to precisely achieve targeted tissues and shorten the procedure time. Modified soft tissue management helped achieve a small surgical wound for uneventful healing.
| Conclusion|| |
Guided tissue regeneration acts as an adjunct to surgical intervention that can employ extensive range of biomaterials. Augmentation with the aid of bone graft materials along with biologically active molecules, in addition to a mechanical barrier in the form of a membrane, would enhance the healing of periapical tissues following periapical surgery.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Alnemer NA, Alquthami H, Alotaibi L. The use of bone graft in the treatment of periapical lesion. Saudi Endod J 2017;7:115-8. [Full text]
Uppada UK, Kalakonda B, Koppolu P, Varma N, Palakurthy K, Manchikanti V, et al
. Combination of hydroxyapatite, platelet rich fibrin and amnion membrane as a novel therapeutic option in regenerative periapical endodontic surgery: Case series. Int J Surg Case Rep 2017;37:139-44.
Kinaia BM, Chogle SM, Kinaia AM, Goodis HE. Regenerative therapy: A periodontal-endodontic perspective. Dent Clin North Am 2012;56:537-47.
Bashutski JD, Wang HL. Periodontal and endodontic regeneration. J Endod 2009;35:321-8.
Goyal B, Tewari S, Duhan J, Sehgal PK. Comparative evaluation of platelet-rich plasma and guided tissue regeneration membrane in the healing of apicomarginal defects: A clinical study. J Endod 2011;37:773-80.
Nakashima M, Akamine A. The application of tissue engineering to regeneration of pulp and dentin in endodontics. J Endod 2005;31:711-8.
Torvi SJ, Munniswamy K. Regenerative dentistry: Current and future perspectives to rejuvenate and reclaim dental tissues. J Int Clin Dent Res Org 2014;6:112-7.
Britto LR, Liang J, Bertucci FJ. The role of biological modulators in endodontic therapy. Rev Fac Odontol Bauru 2000;10:201-8.
Tsesis I, Rosen E, Tamse A, Taschieri S, Del Fabbro M. Effect of guided tissue regeneration on the outcome of surgical endodontic treatment: A systematic review and meta-analysis J Endod 2011;37:1039-45.
Taschieri S, Del Fabbro M, Testori T, Saita M, Weinstein R. Efficacy of guided tissue regeneration in the management of throughandthrough lesions following surgical endodontics: A preliminary study. Int J Periodont Restor Dent 2008;28:265-71.
Yoshikawa G, Murashima Y, Wadachi R, Sawada N, Suda H. Guided bone regeneration (GBR) using membranes and calcium sulphate after apicectomy: A comparative histomorphometrical study. Int Endod J 2002;35:255-63.
Lalabonova H, Daskalov H. Jaw cysts and guided bone regeneration (a late complication after enucleation). J Int Med Assoc Bulg Annu Proc (Sci Pap) 2013;19:401-3.
Sreedevi P, Varghese N, Varugheese JM. Prognosis of periapical surgery using bonegrafts: A clinical study. J Conserv Dent 2011;14:68-72.
] [Full text]
Jansson L, Ehnevid H, Lindskog S, Blomlöf L. Development of periapical lesions. Swed Dent J 1993;17:85-93.
Smith RG, Gassmann CJ, Campbell MS. Plateletrich plasma: Properties and clinical applications. J Lanc Gen Hosp 2007;2:73-7.
Thanikasalam M, Ahamed S, Narayana SS, Bhavani S, Rajaraman G. Evaluation of healing after periapical surgery using platelet-rich fibrin and nanocrystalline hydroxyapatite with collagen in combination with platelet-rich fibrin. Endodontology 2018;30:25-31. [Full text]
Elgendy EA, Abo Shady TE. Clinical and radiographic evaluation of nanocrystalline hydroxyapatite with or without plateletrich fibrin membrane in the treatment of periodontal intrabony defects. J Indian Soc Periodontol 2015;19:61-5.
] [Full text]
Naag S, Savirmath A, Kalakonda BB, Uppada UK, Kamisetty S, Priyadarshini E. Platelet concentrates: Bioengineering dentistry's regenerative dreams. J Dent Res Rev 2015;2:86-90. [Full text]
Tischler M. Platelet rich plasma. The use of autologous growth factors to enhance bone and soft tissue grafts. N
Y State Dent J 2002;68:22-4.
Windley W 3rd
, Teixeira F, Levin L, Sigurdsson A, Trope M. Disinfection of immature teeth with a triple antibiotic paste. J Endod 2005;31:439-43.
Anantula K, Annareddy A. Platelet-rich fibrin (PRF) as an autologous biomaterial after an endodontic surgery: Case reports. J NTR Univ Health Sci 2016;5:49-54. [Full text]
Ehrenfest DM, de Peppo GM, Doglioli P, Sammartino G. Slow release of growth factors and thrombospondin-1 in Choukroun's platelet-rich fi brin (PRF): A gold standard to achieve for all surgical platelet concentrates technologies. Growth Factors 2009;27:63-9.
Huang FM, Yang SF, Zhao JH, Chang YC. Plateletrich fibrin increases proliferation and differentiation of human dental pulp cells. J Endod 2010;36:1628-32.
Jayalakshmi KB, Agarwal S, Singh MP, Vishwanath BT, Krishna A, Agrawal R. Plateletrich fibrin with ßtricalcium phosphateA noval approach for bone augmentation in chronic periapical lesion: A case report. Case Rep Dent 2012;90:58.
Keswani D, Pandey RK. Revascularization of an immature tooth with a necrotic pulp using plateletrich fibrin: A case report. Int Endod J 2013;46:1096-104.
Villar CC, Cochran DL. Regeneration of periodontal tissues: Guided tissue regeneration. Dent Clin North Am 2010;54:73-92.
Rodriguez IA. Barrier membranes for dental applications: A review and sweet advancement in membrane developments. Mouth Teeth 2018;2:1-9.
Kasaj A, Reichert C, Götz H, Röhrig B, Smeets R, Willershausen B.In vitro
evaluation of various bioabsorbable and nonresorbable barrier membranes for guided tissue regeneration. Head Face Med 2008;4:22.
Kher VK, Bhongade ML, Shori TD, Kolte AP, Dharamthok SB, Shrirao TS. A comparative evaluation of the effectiveness of guided tissue regeneration by using a collagen membrane with or without decalcified freeze-dried bone allograft in the treatment of infrabony defects: A clinical and radiographic study. J Indian Soc Periodontol 2013;17:484-9.
] [Full text]
Xue J, He M, Niu Y, Liu H, Crawford A, Coates P, et al
. Preparation andin vivo
efficient anti-infection property of GTR/GBR implant made by metronidazole loaded electrospun polycaprolactone nanofiber membrane. Int J Pharm 2014;475:566-77.
Chen EH, Tofe AJ. A literature review of the safety and biocompatibility of amniontissue. J Impl Adv Clin Dent 2010;2:67-75.
Koob TJ, Rennert R, Zabek N, Massee M, Lim JJ, Temenoff JS, et al
. Biological properties of dehydrated humanamnion/chorion composite graft: Implications for chronic wound healing. Int Wound J 2013;10:493-500.
Chopra A, Thomas BS. Amniotic membrane: A novel material for regeneration and repair. J Biomim Biomater Tissue Eng 2013;18:1-8.
Von Arx T, Bosshardt D. The use of enamel matrix derivative (EMD) for treatment of combined apicomarginal lesions in apical surgery: A retrospective analysis. Eur Endod J 2018;3:146-52.
Bosshardt DD. Biological mediators and periodontal regeneration: A review of enamel matrix proteins at the cellular and molecular levels. J Clin Periodontol 2008;35:87-105.
Koob TJ, Lim JJ, Massee M, Zabek N, Rennert R, Gurtner G, et al
. Angiogenic properties of dehydrated human amnion/chorion allografts: Therapeutic potential for soft tissue repair and regeneration. Vas Cell 2014;6:1-10.
Stahl SS, Froum SJ. Histologic and clinical responses to porous hydroxyapatite implants in human periodontal defects. Three to twelve months postimplantation. J Periodontol 1987;58:689-95.
Su CY, Kuo YP, Tseng YH, Su CH, Burnouf T.In vitro
release of growth factors from platelet rich fibrin (PRF): A proposal to optimize theclinical applications of PRF. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:56-61.
Simonpieri A, Del Corso M, Sammartino G, Ehrenfest DM. The relevance of Choukroun's platelet-rich fibrin and metronidazole during complex maxillary rehabilitations using bone allograft. Part II: Implant surgery, prosthodontics, and survival. Implant Dent 2009;18:220-2.
Pradeep AR, Bajaj P, Rao NS, Agarwal E, Naik SB. Platelet-rich fibrin combined with a poroushydroxyapatite graft for the treatment of three wall intrabony defects in chronic periodontitis: A randomized controlled clinical trial. J Periodontol 2012;83:1499-507.
Ye S, Zhao S, Wang W, Jiang Q, Yang X. A novel method for periapical microsurgery with the aid of 3D technology: A case report. BMC Oral Health 2018;18:85.
Popowicz W, Palatyńska-Ulatowska A, Kohli MR. Targeted endodontic microsurgery: computed tomography-based guided stent approach with platelet-rich fibrin graft: A report of 2 cases. J Endod 2019;45:1535-42.