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 Table of Contents  
Year : 2020  |  Volume : 7  |  Issue : 4  |  Page : 232-235

Ideal tissue regeneration option following periapical surgery

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 Submission13-May-2020
Date of Decision16-May-2020
Date of Acceptance19-May-2020
Date of Web Publication30-Nov-2020

Correspondence Address:
Malti Tuli
Guru Nanak Dev Dental College and Research Institutes, Sunam, Punjab
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdrr.jdrr_37_20

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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 Nov 27];7:232-5. Available from: https://www.jdrr.org/text.asp?2020/7/4/232/302047

  Introduction Top

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.[1] Surgical intervention in the periapical region is aimed to enhance healing, in addition to removing the unhealthy tissues.[2]

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.[3],[4] 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.[5] 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 Top

Tissue engineering aims at functional restoration of impaired or damaged tissues due to pathology or trauma.[6] 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.[7] A scaffold extracellular matrix should contain growth factors to aid stem cell proliferation and differentiation, leading to improved and faster tissue development.[7] Growth factors are biological modulators which can stimulate cell proliferation and differentiation.[8]

  Bone Grafts Top

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.[9]

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.[10],[11] 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.[12] 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.[13] 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.[14] 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.[13] Bone grafts have either osteogenic, osteoinductive, or osteoconductive properties.[15] 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.[13] 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.[16] An added advantage of nanostructured materials is the ability to have an extremely high number of molecules on the surface of the material.[17]

  Biologically Active Molecules Top

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.[15],[17] 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.[18]

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.[19] A study showed that PRF has the ability to multiply pulp cells in addition to enhancing the expression of osteoprotegerin and alkaline phosphatase activity.[20]

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.[21] 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.[22]

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.[23] A recent study on the revascularization of immature pulp apices concluded that PRF acts as a biological connector for neoangiogenesis and vascularization.[24] 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 Top

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.[25] Resorbable membranes are made as an alternative to nonresorbable membranes to avoid an additional surgery.[26] 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.[27] 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.[28]

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.[29]

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.[30]

Amnion membrane is derived from the human placenta. It incorporates growth factors presenting anti-inflammatory and antimicrobial properties.[9] The thickness of the amnion membrane is lesser than collagen membranes, which assists a proper adaption over the osseous defect.[31],[32] Amnion membrane facilitates proliferation of the endothelial cells and angiogenesis, in addition to the recruitment of mesenchymal progenitor cells assisting accelerated wound healing.[33] A recent retrospective study analyzed the healing of teeth with apicomarginal defects treated with apical surgery and enamel matrix derivative (EMD).[34] 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.[35]

  Inference Top

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.[36] 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.[37] PRF facilitates the preservation of the integrity of the bone graft material by revascularizing the bone graft particles through neoangiogenesis.[2],[38] Once PRF starts resorbing slowly, it releases growth factors that maintain a viable field to enhance healing.[39],[40] 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 Top

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.[41]

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.[42]

  Conclusion Top

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.

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Conflicts of interest

There are no conflicts of interest.

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