Periodontal Regeneration – Intrabony Defects: A Consensus Report From the AAP Regeneration Workshop

Mark A. Reynolds, Richard T. Kao, Paulo M. Camargo, Jack G. Caton, Donald S. Clem, Joseph P. Fiorellini, Maria L. Geisinger, Michael P. Mills, Salvador Nares, Marc L. Nevins

Background: Treatment of intra bony defects is an important therapeutic goal of periodontal therapy. The goal of this consensus report was to critically appraise the evidence for the available approaches for promoting periodontal regeneration in intrabony defects. In addition to evaluating the effectiveness of new regenerative approaches for intrabony defects, recommendations for future research were defined for this area. Methods: A systematic review was conducted utilizing computerized search of PubMed and Cochrane databases, supplemented with screening of references in original reports, review articles and a hand search in selected journals. All searches were focused on regenerative approaches with histological evidence of periodontal regeneration (proof of principle), clinical trials and case reports. For purposes of analysis, change in intrabony defect fill was considered the primary outcome variable, with change in clinical attachment as a secondary outcome. The SORT grade was used to evaluate the quality and strength of the evidence. During the consensus meeting, the Group agreed on the outcomes of the systematic review, pertinent sources of evidence, clinical recommendations, and areas requiring future research. Results: The systematic review, which was conducted for the consensus conference, evaluated the effectiveness of the use of biologics for the treatment of intrabony defects. Enamel Matrix Derivative (EMD) and recombinant human Platelet Derived Growth Factor-BB (rhPDGF-BB) with β-tricalcium phosphate (β-TCP) were shown to be efficacious in regenerating intrabony defects. The level of evidence is supported by multiple studies documenting effectiveness. The clinical application of biologics support improvements in clinical parameters comparable to selected bone replacement grafts and guided tissue regeneration (GTR). Factors negatively affecting regeneration included smoking and excessive tooth mobility. Conclusion: Periodontal regeneration in intrabony defects is possible on previously diseased root surfaces, as evidenced by a gain in clinical attachment, decreased pocket probing depth, gain in radiographic bone height, and overall improvement in periodontal health. These clinical findings are consistent with available histologic evidence. Clinical improvements can be maintained over long periods (> 10 years). While bone replacement grafts have been the most commonly investigated modality, GTR, biologics, and combination therapies have also been shown to be effective. Future research should emphasize patient reported outcomes, individual response differences, and emerging technologies to enhance treatment results. Clinical Recommendations: Early management of intrabony defects with regeneration therapies offers the greatest potential for the successful periodontal regeneration. The clinical selection and application of a regenerative therapy or combination of therapies for periodontal regeneration should be based on the clinician's experiences and understanding of the regenerative biology and technology. This decision making process should take into consideration the potential adverse influence of factors such smoking, poor oral hygiene, tooth mobility, and defect morphology on regeneration. Management should be coupled with an effective maintenance program for long-term success.