JOURNAL

DISCUSSION
Sundaram Surendran
AGENDA

Introduction

Critical Appraisal of Paper

Outcome of Appraisal

20XX PRESENTATION TITLE 2

 5.977

AUGMENTATION STABILITY AND EARLY WOUND HEALING

OUTCOMES OF GUIDED BONE REGENERATION IN PERI-IMPLANT
DEHISCENCE DEFECTS WITH L- AND I-SHAPED SOFT BLOCK
BONE SUBSTITUTES: A CLINICAL AND RADIOGRAPHIC STUDY

Eun-Hee Jung Seong-Nyum Jeong Jae-Hong Lee

Dept. of Periodontology Dept. of Periodontology Dept. of Periodontology

This research was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science & ICT (NRF-2017R1C1B5014849
and NRF-2019R1A2C1083978) and Wonkwang University in 2017.
 CRITICAL APPRAISAL
(TITLE)

GTR with L and I GTR with Au g m e n t a t i o n S t a b i l i t y

Peri-implant Demineralized bovine a n d E a r l y Wo u n d
shaped Demineralized
Dehiscence bone mineral Healing
bovine bone mineral

TYPE OF STUDY: Retrospective Clinico – Radiographic Study (Sep 2016 to May 2020)

Ti t l e f a i l s t o m e n t i o n t h e n a t u r e o f t h e s t u d y p r o p e r l y
INTRODUCTION

The basic premise for Guided Tissue Regeneration

technique is to allow for osseous regeneration prior to
soft tissue migration into the area of interest. This is
accomplished with the use of membranes that prevent the
migration of the soft tissue element into the bony defect.

5
 Wound (a) Clean, (b) Contaminated, (c) Clean Contaminated

Complications of
Wound Healing (a) Non – Union (c) Wound Dehiscence (d) Suppuration and breakdown (e)
Fibrosis and Scaring

Types of wound
(a) Healing by Primary Intention (b) Healing by Secondary Intention
healing

Healing Template Tissue damage → Haemorrhage and Haemostasis →

Inflammation → Transient Scaffold → Regeneration/ Repair
→ Remodelling

PRIMER
 Guided bone regeneration (GBR), which is a well-
established and widely used technique for
augmentation of horizontal and vertical peri-implant
bone defects, has shown excellent clinical outcomes
in recent decades (Polimeni et al., 2006; Elgali et al.,
2017). A systematic review reported that the long-
term survival rate of GBR-based implants was 95.7%
(range, 84.7%–100%), and other systematic reviews
also confirmed that almost all GBR techniques
showed a success rate higher than 90% (range, 90%–
100%), irrespective of the various types of bone
grafting materials (Chiapasco & Zaniboni, 2009;
Clementini et al., 2012).

PRIMER
 P Primary wound coverage

A Adequate blood supply and angiogenesis,

Dr. Dahlin
1988
S Space creation and maintenance,

S Wound stability

WANG & BOYAPATI, 2006

 Types of graft (a) Autograft, (b) Isograft, (c) Allograft, (d) Alloplast, (e) Xenograft

Based on Activity (a) Osseoconductive (b) Osseoinductive (c)Osteogenic

Based on Processing (a) Demineralized (b) Deproteinized (c) Deep Freeze

Membranes (a)Resorbable (b) Non resorbable

PRIMER
 CRITICAL APPRAISAL
(INTRODUCTION)

To retrospectively evaluate whether GBR with L and I

shaped soft bone block substitutes in combination
with collagen membrane differs from GBR with
particulate bone substitute in terms of augmentation
stability and early wound healing

AIM

A null hypothesis has not been stated

10
 CRITICAL APPRAISAL
(MATERIALS & METHODS)

Data Values
91 subjects
24 L GBR Male 40
Female 51
STROBE Observational Guidelines Average Age 54.4 years (19 -82)
22 I GBR
Central Incisor 45
Protocol Approval No.W1612/004- Lateral Incisor 36
45 DBBM
001 Wonkwang University Canine 10

Presence of intrabony and buccal dehiscence in Ant. Implanted Immediate or early loading
teeth
Heavy smoker > 10 cigarettes/day
Re-entry surgery within 5 months ± 2 weeks after placement
Occurrence of peri implant infection and suppuration during
Healthy or well controlled systemic disease the 5 month healing period before re entry surgery
Full mouth bleeding score/ probing & full mouth plaque score
<25%

T h e p o w e r a n a l y s i s i n d i c a t e d t h a t a s a m p l e s i z e o f 9 1 ( a m i n i m u m o f o v e r 2 2 p e r g r o u p ) wo u l d h a v e
o v e r 8 0 % p o w e r t o d e t e c t a m e d i u m e ff e c t s i z e o f 0 .2 5 , w i t h a s i g n i f i c a n c e l e v e l o f 0 .0 5 .
 CRITICAL APPRAISAL
(MATERIALS & METHODS)

Procedures were done by board certified periodontist and

Osstem TS III implant used

Group GBR – L : Geistlich Bio-Oss® Collagen 250 mg covered with

Native Bilayer Collagen Membrane,
Group GBR – I : Geistlich Bio-Oss® Collagen 250 mg covered with
Native Bilayer Collagen Membrane,
Group GBR – P : Geistlich Bio-Oss® 0.25 or 0.5 g of 0.25–1 mm
granules.
 CRITICAL APPRAISAL
(RADIOGRAPHIC OUTCOME MEASURES)

To assess the horizontal thickness (HT) of the augmented hard

tissue, lines perpendicular to the implant's long axis at the implant
shoulder (HT0) and 2 mm (HT2) and 4 mm (HT4) below the
coronal portion of the implant were drawn on the sagittal CBCT
images.

Vertical thickness (VT) following the long axis of the coronal

portion of the implant,

45° vertical thickness (45-VT) at a 45° positive angle relative to

the long axis of the coronal portion of the implant were measured to
evaluate the vertical augmentation,

CBCT obtained after surgery and at 5 month follow up.

CS 8100 3D®, Carestream/ Osirix X 11.0 64-bit version, Pixmeo SARL

 CRITICAL APPRAISAL
( CLINICAL OUTCOME MEASURES)

Early postoperative discomfort (severity/duration of subjective pain and swelling) and

wound healing (wound dehiscence and membrane exposure) were assessed using a self-
report questionnaire and clinical evaluation 2 weeks after surgery.

Stability of the implants (Periotest values [PTVs]) was recorded 5 months after surgery.

Visual analog scale (VAS) score (0–10); Periotest M®, Medizintechnik Gulden
 CRITICAL APPRAISAL
( STATISTICS AND RESULTS)

Shapiro – Wilks Normalcy test for the data revealed a non parametric data set, therefore assessment was carried out with
Mann Whitney U test, Kruskal Wallis and Chi Square test (IBM SPSS)

OUTCOME MEASURES RESULTS

• No significant differences between the GBR-L and GBR-I
groups were found,
HORIZONTAL BONE CHANGE • The change at HT0 in the GBR-P group was significantly
different from that in the GBR-L and GBR-I groups.
RADIOGRAPHI
C OUTCOMES • At VT GBR-I group was significantly more stable than that of the
GBR-P,
VERTICAL BONE CHANGE • 45-VT, the GBR-L group showed better augmentation stability
than the GBR-I group.

PAIN AND WOUND DEHISENCE Not statistically significant among groups

CLINICAL
OUTCOMES
IMPLANT STABILITY Not statistically significant among groups
 CRITICAL APPRAISAL
( DISCUSSION & CONCLUSION)

W h y B o ne B l o c k ?
Because of better bone gain compared to particulate grafting ( 3.7 mm ±
1.2 mm horizontally and 3.7 mm ± 1.4 mm vertically to 4.5 ± 1.2 mm
and 5.8 mm ± 2.8 mm
Why Soft Bone
Block ?
Hard, brittle, difficulty in handling, displacement after stabilization
screw placement, rough corners cause soft tissue irritation
Limitations of the Study

Retrospective study, short term follow up, soft tissue parameters not
completely included, proficiency and skill limitations.

Within the limitations of this study, L- and I-shaped DBBM-Cs used for GBR were more beneficial for peri-
implant bone defects in terms of horizontal augmentation stability than DBBM after 5 months of the hard tissue
healing period.
THANK YOU