Volume 7, Issue 3 (Journal of Research in Dental & Maxillofacial Sciences Summer 2022)                   J Res Dent Maxillofac Sci 2022, 7(3): 181-193 | Back to browse issues page

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Hassani S, Hashemi moghaddam F, Akbari foroud S, Aghayan S. Techniques and Materials for Treatment of Bone Loss Due to Periodontitis: A Review. J Res Dent Maxillofac Sci. 2022; 7 (3) :181-193
URL: http://jrdms.dentaliau.ac.ir/article-1-326-en.html
1- Private Practice, Tehran, Iran
2- Periodontology Dept, Faculty of Dentistry,Islamic Azad University of Medical Sciences, Tehran, Iran. , shabnamaghayan@yahoo.com
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Background and Aim: The first purpose of treatment of periodontal disease and bone loss is to regenerate the lost structures and preserve the sound residual tissues. Different techniques and materials are utilized for alveolar bone loss treatment. This review summarizes the techniques and materials utilized for treatment of alveolar bone loss due to periodontitis.  
Materials and Methods: A search was performed in PubMed, Cochrane Library, and Google Scholar databases from 1990 to 2021. Totally, 133 studies were collected and reviewed, and finally, 31 studies were selected for the analysis.
Results: Of 31 papers, 13 were about intra-bony defects, and others were about furcation involvement defects. Each article suggested different techniques and materials. Clinical parameters such as plaque index, gingival index, probing pocket depth (PPD), clinical attachment loss (CAL), and gingival margin position had been measured in studies, and a few techniques showed better results than others. Treatment of furcation defects is difficult in periodontal therapy. We should note that surgical procedures do not have any superiority over non-surgical procedures.
Conclusion: In conclusion, to decide about the best technique, site of defect, severity of disease, the available materials, and the clinician’s knowledge should be considered.
 Key Words: Alveolar bone Loss; Furcation defects; Periodontitis; Regeneration


Periodontitis and gingivitis are among the foremost common inflammatory conditions [1,2]. Periodontitis is identified by progressive destruction of tooth-supporting structures. It is characterized by the loss of periodontal tissue support manifested by clinical attachment loss (CAL), radiographic alveolar bone loss, periodontal pocket formation, and gingival bleeding [3]. Periodontitis is classified into stages one to four based on disease severity, and grades A to C based on disease progression [4]. Periodontal bone destruction may result in vertical or horizontal bone defects, based on the direction and extent of apical propagation of plaque-induced defect [5].
The ultimate goal of periodontitis treatment and alveolar bone reconstruction is to regenerate the lost structures due to infection, trauma, or congenital anomalies [3]. The conventional treatment of periodontitis aims to inhibit the progression of disease by minimizing the pathogenic microbiota and stopping the inflammatory process [6]. Based on a guideline published by Sanz et al., [3] the treatment of periodontitis should be planned step by step to avoid unnecessary invasive treatments. The primary step to manage all stages of periodontitis is to change the patient's behavior. These behavioral changes include supragingival dental biofilm removal, improvement of oral hygiene, professional plaque removal, and risk factor control. The second step is to control the subgingival biofilm and calculus using adjunctive agents, host-modulating agents, subgingival local antimicrobial agents, and systemic antimicrobial treatment. The third step for non-responding areas is to repeat subgingival instrumentation with or without additional treatments, periodontal flap surgery, and resective and regenerative periodontal surgical procedures. Based on this guideline, the suggested treatment for class II and III furcation involvement defects of mandibular molars with pockets is regenerative or resective, except for maxillary class II furcation defects, for which the provided treatment is non-regenerative [3]. Various methods are suggested to treat bone defects including open flap debridement, odontoplasty, root resection, regeneration, and extraction [2]. Root resection or root amputation refers to removal of one root of a multi-rooted tooth; while, in apicoectomy, only the root apex is removed. In hemisection, one root and its related coronal structure are removed. In class III and multiple class II furcation involvement defects, non-surgical instrumentation, tunneling, root separation, or root resection and biomimetic agents, like enamel matrix derivatives, platelet-rich plasma, platelet-derived protein, and bone morphogenetic proteins may be used [3]. However, the results of these procedures are influenced by local and systemic factors. Local factors that need to be controlled prior to initiation of treatment include removal of restoration overhangs, cervical enamel projections, enamel pearls, and bifurcational ridges.
Different materials such as bone morphogenetic proteins, endothelial growth factor, fibroblast growth factor, human leukocyte antigen, insulin-like growth factor, interleukins, platelet-derived growth factor, and transforming growth factor are used as graft materials. The materials that are used as graft must have optimal mechanical and physical properties and should be biocompatible [4].
Bone defects due to periodontitis are classified into four main groups of horizontal, vertical, crater-shaped, and furcation involvement defects. In teeth with multiple roots, periodontitis causes periodontal destruction between the roots. Molars with furcation defects are at higher risk for attachment loss and tooth loss [5,7-9]. This review summarizes the techniques and materials utilized for treatment of alveolar bone loss due to periodontitis.

Materials and Methods

A search was done through PubMed, Google Scholar, and Cochrane Library from 1990 to 2021 using "periodontitis", "bone loss", "treatment", "bone regeneration" and "graft" as keywords. The primary screening was based on relevance of the titles and the keywords. A study was selected for inclusion if it evaluated periodontitis, treatment, and bone loss and was published in English. The second screening was based on full-text analysis. Studies on techniques and materials used to treat bone loss due to periodontitis were included. We included randomized clinical trials, non-randomized clinical trials, and ex-vivo and in-vitro studies. The purpose of the search was to collect all English articles from 1990 to 2021 (n=133).


This review evaluated 18 studies about furcation involvement defects, and 13 studies about intra-bony defects. There was no specific study on crater defects. Only two studies were on animals, and others were human studies. There are many studies on treatment of furcation involvement defects. Of the assorted furcation involvement defects, class II is the simplest candidate for regenerative treatments [10-12]; thus, most of the studies were about class II furcation involvement defects.
According to Dommisch et al., the treatment of class II furcation defects is simpler than class III, and surgical procedures like root amputation, root separation or resection, and tunneling have no superiority over non-surgical procedures like scaling and root planing. In their study, they first evaluated the tooth survival, and then vertical probing attachment gain, and reduction of probing pocket depth (PPD) [13].
Garg and Pradeep [14] performed scaling and root planing along with 1.2% rosuvastatin and 1.2% atorvastatin to treat furcation defects and showed that rosuvastatin improved all clinical parameters. Statins have anti-inflammatory, immunomodulatory, antioxidant, antithrombotic, and anti-inflammatory properties, and can stabilize the endothelium, and induce osteoblastic differentiation, and thus, they may be used to treat periodontitis [15-17].
Bevilacqua et al. reported that open flap debridement was more cost-effective than surgical techniques but it was less effective for improvement of bleeding on probing, PPD, periodontal height, and CAL after one year of follow-up. They showed that root recontouring significantly decreased inflammation [18].
Oliveira et al. suggested different treatments for furcation defects such as guided tissue regeneration (GTR) with polytetrafluoroethylene barrier (ePTFE), enamel matrix derivative (EMD), β-tricalcium phosphate, hydroxyapatite, and bioresorbable collagen membrane. They found no significant difference among these treatment approaches [19] but all of them are associated with a risk of treatment failure due to systemic conditions or patient-related factors [20].
EMD has remarkable effects on cementum formation, periodontal ligament, alveolar bone, epithelial cell growth, transforming growth factor β, fibroblast growth factor, extracellular matrix metalloproteinases and osteoclast maturation. Soares et al. showed that EMD had no significant superiority over treatment with open flap debridement and beta-tricalcium phosphate/hydroxyapatite bone graft [21].
Murphy and Gunsolley compared GTR with other treatments. They found a significant difference between GTR and open flap debridement, and showed that augmentation with GTR barrier with a particulate graft enhanced vertical pocket depth, vertical periodontal attachment level, and horizontal open probing attachment [10].
Jaiswal and Deo found that using bone graft and GTR with or without EMD had significant effects on CAL, horizontal probing depth, and PPD compared with open flap debridement alone after 12 months of follow-up [22]. Avila-Ortiz et al. showed that regenerative therapies had greater effects on maxillary molar class III furcation involvements and maxillary pre-molar class II and III furcation involvements [23].
Mineral trioxide aggregate (MTA) and calcium enriched mixture (CEM) cement are also used to treat furcation involvement defects. MTA was introduced for lateral perforation repair in 1993 by Loma Linda University. In 2006, CEM cement was introduced to dental market [24]. MTA is a type I Portland cement derivative composed of dicalcium silicate, tricalcium silicate, tricalcium aluminate, and tetra calcium aluminoferrite. MTA induces the formation of hard tissue bridges, and CEM cement exhibits effects like those of MTA [24]. Ghanbari et al. evaluated varieties of cements and found that MTA and CEM cement with collagen membrane had no difference with each other, and both enhanced the treatment of class II furcation defects [25].
Among platelet concentrates, leukocyte- and platelet-rich fibrin is a second-generation blood product prepared by peripheral blood centrifugation with no anticlotting agent to obtain a dense three-dimensional clot architecture with concentrated platelets, fibrin, leukocytes, cytokines, and growth factors. Paolantonio et al. suggested treating intra-bony defects with leukocyte- and platelet-rich fibrin and autogenous bone graft and reported that they are superior to EMD [26]. Del Fabbro et al. reported that not many studies are available on autologous platelet concentrates in combination with other methods or materials [27].
A study by Kaya et al. on horizontal bone defects found no significant difference between treatment with particulate demineralized bone matrix and putty demineralized bone matrix and open flap debridement in treatment of horizontal treatment defects [28].
Vertical defects are divided into three groups: 1) wall vertical defects, 2)wall vertical defects, and 3)wall vertical defects. Bio-Oss has been utilized for several years. Bovine porous bone mineral (Bio-Oss) could be a relatively new material for periodontal regeneration. It is prepared by protein extraction of bovine bone, which leads to formation of a structure like human cancellous bone and might enhance bone formation [29].
Freeze-dried bone allograft offers certain advantages to autogenous sources for bone graft material. Richardson et al. found no significant difference between bovine-derived xenograft and demineralized freeze-dried bone allograft in outcome of treatment [30].

Combined treatment modalities with GTR are being investigated to obtain more reliable results. A combination of GTR with low-level laser therapy is one suggested modality. Dogan et al. used low-level laser therapy with GTR and reported significant improvements [7].
Mesenchymal stem cells are multipotent cells that can differentiate into cementoblasts, osteoblasts, and periodontal fibroblasts.
Platelet-rich fibrin (PRF) is a second generation platelet concentrate that enriches the fibrin membranes with platelets and growth factors. PRF looks like a fibrin network and causes more efficient cell migration and proliferation. It can serve as a carrier for cells essential for tissue regeneration. PRF can serve as an appropriate scaffold for in vitro culture of human periosteal cells, which can be used for bone tissue engineering [31]. Simsek et al. found that using autogenous cortical bone alone or with platelet-rich plasma (PRP), and mesenchymal stem cells with PRP significantly improved periodontal parameters, but PRP alone caused no significant change [32].

Lohi et al. found that using bioactive ceramic composite granules with PRF yielded superior results compared with its application alone [33].
Porous hydroxyapatite bone graft material has shown clinically acceptable results in filling of periodontal intra-bony defects and optimal osteoconductivity. Pradeep et al. [34] showed that using hydroxyapatite with PRF and open flap debridement improved regenerative effects for treatment of 3-wall vertical defects. Sharma and Pradeep found that using autogenous PRF with open flap debridement improved bone fill of 3-wall defects [35].
 Mathur et al. showed that both PRF and autogenous bone graft significantly improved the treatment of 3-wall defects [36].
Different graft materials are successfully utilized for treatment of intra-bony defects. The materials  most typically used are autografts and allografts. Prakash et al. [37] indicated that adding hard tissue replacement polymers (such as Bioplant HTR) as a bone graft material to open flap
debridement technique made not much difference in properties of defects.

Kinaia et al. demonstrated that using resorbable membrane for class II furcation involvement made a substantial difference  regarding vertical bone loss compared with non-resorbable membrane, and significantly changed the periodontal parameters as compared with open flap debridement. They concluded that using xenograft with resorbable membrane can improve the results of treatment [1].
A number of bioabsorbable membranes result in greater crestal bone resorption than non-resorbable membranes. The best membrane for GTR is ePTFE, a porous Teflon membrane. Walters et al. [38] found no difference in results of treatment with porous and non-porous ePTFE membranes with xenograft.
Eickholz et al. indicated that using GTR with or without synthetic bioabsorbable polyglactin 910 barriers yielded better outcomes than periodontal surgery since using bioabsorbable barriers in GTR eliminates the need for a second surgical procedure to remove the non-resorbable membrane [39]. Jenabian et al. evaluated Bio-Gen and showed that using it with connective tissue was more effective for bone filling than Bio-Gen with collagen membrane [2].  Becker W and Becker BE used ePTFE as a barrier membrane with open flap debridement and found this method to be effective after 8 years of follow-up [40]. 
Jung et al. found contradictory results about using bovine hydroxyapatite/collagen as a membrane in 1-wall vertical defects. Still, utilization of a barrier membrane for non-contained-type defects is suggested to enhance the graft material's stability and condense it [41]. Gurinsky et al. [42]
demonstrated that adding demineralized freeze-dried bone allograft to EMD improved the treatment outcome in hard tissue.

Jepson et al. found that regenerative techniques significantly affected horizontal CAL gain, vertical CAL gain, and PPD reduction, compared with open flap debridement, and employing a non-resorbable membrane with bone replacement graft is the best treatment for furcation defects [43].
Table 1 presents a summary of reviewed articles.


To choose the best technique to treat our patients, we must always consider various factors such as the location of defect, the patient's systemic condition, oral hygiene of patient, and other factors that may affect the treatment results. For treatment of furcation involvement defects, we must
always pay attention to the followings:

1. There is no superiority of surgical procedures over non-surgical procedures. It has been shown that both treatment methods lead to persistent reduction in gingival inflammation, plaque, and calculus, and neither process seems to be superior concerning these parameters.
2. Open flap debridement is the most cost-effective method.
3. Resorbable membranes are better than non-resorbable membranes and open flap debridement.
4. GTR is one of the best treatments. The clinical superiority of GTR compared with standard therapy (open flap debridement) for class II furcation defects has been documented, probably as the result of regeneration. 
5. Low-level laser therapy may improve the results of treatment. 
6. For intra-bony defects, regenerative techniques are the most effective choices.

FI: furcation involvement, SRP: scaling and root planning, OFD: open flap debridement, BRG: Bone replacement grafts, HCAL: horizontal clinical attachment level, VCAL: vertical clinical attachment level, PPD: Probing pocket depth, HBL: horizontal bone level, FHC: furcation horizontal component, FBD: fornix to base of defect, CAL: clinical attachment level, EMD: enamel matrix protein derivative, BTCP: beta-tricalcium phosphate, HA: hydroxyapatite, MTA: mineral trioxide aggregate, CEM: calcium enriched mixture, GTR: Guided tissue
regeneration, BG: Bone graft, ACB: autogenous cortical bone, MSCs: mesenchymal stem cells, PRP: platelet rich plasma , APC: autologous platelet concentrates, ePTFE: expanded
polytetrafluoroethylene, ABG: Autogenous bone graft
Type of Study: Review article | Subject: Periodontology

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26. Paolantonio M, Di Tullio M, Giraudi M, Romano L, Secondi L, Paolantonio G, Graziani F, Pilloni A, De Ninis P, Femminella B. Periodontal regeneration by leukocyte and platelet-rich fibrin with autogenous bone graft versus enamel matrix derivative with autogenous bone graft in the treatment of periodontal intrabony defects: A randomized non-inferiority trial. J Periodontol. 2020 Dec;91(12):1595-608. [DOI:10.1002/JPER.19-0533] [PMID]
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28. Kaya Y, Yalim M, Bahçecitapar M, Baloş K. Comparison of applying particulate demineralized bone matrix (DBM), putty DBM and open flap debridement in periodontal horizontal bone defects. A 12-month longitudinal, multi-center, triple-blind, split-mouth, randomized, controlled clinical study. Part 1 - clinical and radiographic evaluation. J Oral Rehabil. 2009 Jul;36(7):524-34. [DOI:10.1111/j.1365-2842.2009.01958.x] [PMID]
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31. Pradeep AR, Bajaj P, Rao NS, Agarwal E, Naik SB. Platelet-Rich Fibrin Combined With a Porous Hydroxyapatite Graft for the Treatment of 3-Wall Intrabony Defects in Chronic Periodontitis: A Randomized Controlled Clinical Trial. J Periodontol. 2017 Dec;88(12):1288-96. [DOI:10.1902/jop.2012.110722] [PMID]
32. Simsek SB, Keles GC, Baris S, Cetinkaya BO. Comparison of mesenchymal stem cells and autogenous cortical bone graft in the treatment of class II furcation defects in dogs. Clin Oral Investig. 2012 Feb;16(1):251-8. [DOI:10.1007/s00784-010-0486-7] [PMID]
33. Lohi HS, Nayak DG, Uppoor AS. Comparative Evaluation of the Efficacy of Bioactive Ceramic Composite Granules Alone and in Combination with Platelet Rich Fibrin in the Treatment of Mandibular Class II Furcation Defects: A Clinical and Radiographic Study. J Clin Diagn Res. 2017 Jul;11 (7):ZC76-ZC80.
34. Pradeep AR, Bajaj P, Rao NS, Agarwal E, Naik SB. Platelet-Rich Fibrin Combined With a Porous Hydroxyapatite Graft for the Treatment of 3-Wall Intrabony Defects in Chronic Periodontitis: A Randomized Controlled Clinical Trial. J Periodontol. 2017 Dec;88(12):1288-96. [DOI:10.1902/jop.2012.110722] [PMID]
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37. Prakash S, Sunitha J, Abid S. Evaluation of HTR polymer (Bioplant HTR) as a bone graft material in the treatment of interproximal vertical bony defects: a clinical and radiological study. Indian J Dent Res. 2010 Apr-Jun;21(2): 179-84. [DOI:10.4103/0970-9290.66630] [PMID]
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