Combining Hyaluronic Acid With a Xenograft to Treat Periodontal Infrabony Defects: A Report of 18 Cases

Introduction

Infraosseous periodontal defects can be treated using tissue regeneration techniques. Minimally invasive surgery combined with regenerative biomaterials such as hyaluronic acid and xenografts may improve healing.

Hyaluronic acid (HA) is a key component of the extracellular matrix involved in cell migration and is present in various periodontal cells. In vitro studies have shown that HA induces early osteogenic differentiation of periodontal ligament cells and increases the migratory and proliferative properties of gingival fibroblasts and preosteoblasts, making it an interesting biomaterial for bone and periodontal regeneration. In addition, HA can induce the proliferation and osteogenic differentiation of bone marrow cells and preosteoblastic cells, playing an important role in the early and late stages of bone formation. Accordingly, animal studies evaluating the effects of HA in the treatment of intrabony defects and recession have revealed periodontal regeneration through the formation of cementum, periodontal ligament, and bone.

Current evidence suggests that HA may not only positively influence periodontal regeneration but may also have a potential role in bone formation. Recent systematic reviews have shown that the use of HA in nonsurgical and surgical periodontal treatment may have a positive effect on clinical outcomes, with a reduction in probing pocket depth (PPD), a gain in clinical attachment level (CAL), and a decrease in bleeding on probing (BOP).

Combined therapies involving bone grafting help maintain the volume of the healing space in the infraosseous defect and stabilize the blood clot, thereby improving clinical outcomes.

Materials and methods

18 patients with stage III or IV periodontitis and 19 intrabony lesions were treated with minimally invasive periodontal regenerative surgery (Fig 1). After buccal and lingual para-apical anesthesia, a horizontal papilla preservation incision, MPPT (if the interdental space is greater than 2mm) or SPPF (if the interdental space is less than 2mm), is made with a microblade (MJK® BW002). A unilateral M-MIST flap (if the lingual cortical plate is preserved) or bilateral MIST flap (if the lingual cortical plate is absent) is then raised using a papilla elevator (Fig 2). The inflammatory tissue is removed using mini-curettes and mini-ultrasonic instruments, and the infraosseous defect is then regenerated by combining hyaluronic acid (Hyadent®, Regedent) with a xenograft (Collapat II ®, Symatese) (Fig 3). Primary closure is achieved using horizontal mattress and simple interrupted sutures (5.0 nylon suture) (Fig 4).

Fig 1: Following nonsurgical periodontal therapy, clinical examination reveals a residual pocket depth of 9mm on the mesial aspect of 36. Radiographic examination allows more detailed analysis of the characteristics of the infraosseous defect (infraosseous depth 5.5mm, width 1.7mm, angle 16.2°)

Fig 2: Horizontal MPPT-type papilla preservation incision and unilateral M-MIST-type flap elevation.

Fig 3: After removal of the granulation tissue, hyaluronic acid (Hyadent®, Regedent) and the bone graft (Collapat II®, Symatese) are placed.

Fig 4: The infraosseous defect has been grafted, with sutures consisting of a horizontal mattress suture at the base of the papilla and two simple interrupted sutures at the papilla tip. Hyaluronic acid is applied over the sutures.

The primary outcome measure is the clinical attachment level at one year postoperatively (Fig 5).The secondary outcome measures are probing pocket depth and gingival recession height.

Results

Results were assessed at one year postoperatively. Mean clinical attachment gain was 3.68 ± 1.71 mm. Probing depth was reduced by a mean of 4.94 ± 1.71 mm. Recession increased by a mean of 1.31 ± 1.67 mm.

Discussion

The results are comparable to those reported in the literature. The study by Bozic et al., combining a xenograft (Bio-Oss®) with hyaluronic acid, showed a clinical attachment gain of 3.65 ± 1.67 mm, a reduction in pocket depth of 4.54 ± 1.65 mm, and an increase in gingival recession of 0.89 ± 0.59 mm across 27 infraosseous defects. A meta-analysis by Matarasso et al. showed that surgical treatment of infraosseous defects combining enamel matrix derivative proteins with a bone graft resulted in a clinical attachment gain of 3.76 ± 1.07mm, a reduction in pocket depth of 4.22 ± 1.20 mm, and an increase in recession of 0.76 ± 0.42 mm.

Fig 5: One-year postoperative situation. A 3mm pocket with no bleeding and radiographic resolution of the infraosseous defect are observed.

Conclusion

The results obtained in patients treated with minimally invasive surgery combined with hyaluronic acid and a xenograft showed improvement in clinical and radiographic parameters.

Authors: A. Brincat, C. Sadowski, R. Ohanessian, T. Ranchain, M. Crest, D. Golzmann, M. Blanc, A.antezack, V. Monnet-Corti

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