HIP marrow implants in periodontal surgery

British Journal of Oral Surgery

(1974), Iz, 40-45

HIP MARROW IMPLANTS IN PERIODONTAL SURGERY M. MIDDA, B.D.S., F.D.S.,

F.F.D.

University of Bristol Dental School Summary. Intra-oral transplants of marrow material obtained from the anterior iliac crest under local anaesthesia using trephine biopsy needles were placed in 74 periodontal defects in 22 patients. There was an average pocket reduction of 4.7 mm with a minimum of post-operative problems. It is suggested that this method of obtaining small amounts of autogenous bone may be of value to the oral surgeon in the repair of other minor oral bony defects.

INTRODUCTION IN the past decade the profession has accepted that dental plaque is the major aetiological factor in the causation of periodontal disease. Thus, prevention and the treatment of marginal lesions can be accomplished by the daily frictional removal of this bacterial film. In order ‘to facilitate cleansing, simple techniques such as curettage and gingival recontouring can be performed so that the patient is able to maintain the tissues in a state of health. However, many of the deeper infra bony lesions will not respond to simple cleaning and soft tissue surgery and pocket elimination via flap procedures in these cases has been the treatment of choice. The ultimate treatment plan in periodontal disease is not only the elimination of the pocket but also restoration of the lost supporting tissues. To this end, many efforts have been made to find a material which would induce regeneration of bone in the periodontal osseous defects. Many synthetic materials have been tried but none of these has proved to be a satisfactory substitute for bone and, in particular, autogenous bone from marrow spaces. Autogenous bone has the least chance of host rejection and the porous consistency of cancellous bone increases the potential for rapid revascularisation and subsequent graft survival. In addition, haemopoietic marrow probably enhances the bone inductive mechanisms because it contains many undifferentiated cells. Mowlem (194) and Flint (1964) devised methods of removal of autogenous iliac crest material and Williams (1973) reviewed other donor sites for obtaining bone grafts but all of these meant the administration of a general anaesthetic and some degree of post-operative discomfort with limitation of movement and involved the admission of the patient to hospital. Most periodontal procedures are performed on outpatients and any method of obtaining graft material should be compatible with local anaesthetic techniques and the need for minimal post-operative care. Cancellous material can be obtained from the mouth using rongeurs in the maxillary tuberosity area as suggested by Hiatt and Schallhorn (1973) or by ‘blending’ bone from other intra-oral sites (Diem, et al. 1972). These techniques depend upon a sufficient supply of intraoral donor material being available. Recently Dragoo and Irwin (1972) modified the Turkel Trephine Biopsy Needles (Fig. I) so that sufficient cancellous bone can be removed from the iliac crest under local anaesthesia to repair periodontal defects. Received 20.3.74. Accepted 29.3.74 40

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METHODS The patient is normally offered and encouraged to accept intravenous sedation The latter is given to ensure a degree of analgesia by diazepam and pethidine. that diazepam cannot supply. Prophylactic antibiotic therapy is instituted, i.e. 500,ooo I.U. crystalline pencillin and 300,000 I.U. procaine pencillin intramuscularly half an hour pre-operatively followed by phenoxymethyl pencillin 250 mg q.d.s. Alternative methods are substituted for patients who are allergic to penicillin or have had penicillin within the preceding 3 months. The patient is placed in a supine position with the pelvis elevated by a small pillow. Sedation is obtained and the skin area around the anterior crest prepared using a hibitane mixture followed by draping with sterile towels. I per cent lignocaine is then injected 3 cm dorsal to

FIG. I Turkel

Trephine

biopsy needles.

the anterior spine to the centre of the crest using I to 2 ml subcutaneously. The infiltration is then extended to the medial and lateral periosteal areas using approximately 8 ml. A stab incision is made with a scalpel down to the periosteum to allow entry of the outer needle and stylet of the Turkel needle. The needle is guided so that it penetrates the periosteum of the central iliac crest and rotated through a 30 degree arc anti-clockwise until the cortical plate is engaged to a depth of 3 mm on a line from the anterior iliac spine to the pubis. (Figs 2 and 3.) The stylet is now withdrawn and the inner needle inserted into the stable outer needle. Continuing the 30 degree rotation, the inner trephine penetrates the remaining cortical bone and a drop in resistance is found as it enters the medulla. The inner needle is rotated in the cancellous bone until resistance is met again indicating that it is in contact with the lateral or medial cortical plate. It is then withdrawn slowly so as not to create a marked negative pressure within the ileum. Pethidine is used in the sedation as the local anaesthetic will not overcome the slight discomfort associated with this part of the procedure. The inner needle stylet is used to remove the core of bone and to place it into a sterile normal saline holding solution

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(Fig. 4). By varying the angulation of the outer needle and re-insertion of the inner as many as 15 to 20 cores may be taken from the one skin and bone puncture point. When the required amount of bone has been obtained, the outer needle is withdrawn and pressure applied to the operative site which is later dressed with plastic skin and a pressure bandage.

Anterior superior iliac spine Pubic tubercle Pubic symphysis

FIG.

Anatomical

landmarks

FIG.

Outer needle

2

for obtaining

graft material.

3

stabilised

in iliac cortex.

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For the purposes of this report, the areas in the mouth selected for therapy by this method were: (u) One or surgical (b) Defects method

two wall infra bony defects which had failed to respond to normal procedures. so large on initial examination that this was thought to be the only available for saving the teeth.

As with all periodontal patients, pre-surgical therapy was instituted which consisted of plaque control programming, scaling and curettage. Patients were

FIG. 4 Typical

core of autogenous

iliac marrow.

assessed 6 to 12 weeks later for co-operation and suitability for surgery. The pocket depths were recorded using the gingival margin to the base of pocket measurements which normally is related to the alveolar bone height. The zones of attached gingiva and the gingival height from the cemento-enamel junction were noted and all these measurements were taken pre- and post-operatively to record the net reduction in pocket depth. Results were obtained from 6 weeks to 17 months post-operatively. Twentytwo cases with a total of 74 defects were operated upon. Initial mean sounding depth (gingival margin/bone) was 8.1 mm with a range of 5-12 mm. Post-operatively, there was a final mean sounding depth (gingival margin/bone) of 3.4 mm with a range of I ‘5-49 mm. This gave an average pocket reduction of 4.7 mm. Measurements made from the cemento-enamel junction indicate an average of 1.5 mm gingival recession or operative loss. Thus, there was a gain of bony height of 3.2 mm. CASE REPORT One of the typically treated lesions is demonstrated. Figure 5, A, demonstrates radiographically the hemiseptal defect and Figure 5, B shows the osseous defect after

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curettage and minimal root planing. The marrow graft was obtained from the iliac crest and inserted into the defect (Fig. 5, c), and the wound sutured. The radiographic appearance I year after operation (Fig. 5, D) shows the degree of bony regeneration obtained.

C, Defect filled with graft material.

D, Post-operative FIG.

radiograph later.

one year

5

DISCUSSION No complications were found or complained slight haematomas that had disappeared by the infection occurred at the recipient or donor sites in prophylactic antibiotic cover. Schallhorn (1972) operative infection using a bacteriostatic drug,

of at the donor sites other than 2nd week. No post-operative these series, due, it is felt, to the has reported one case of postTetracycline. In the author’s

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opinion the antibiotic used should be bacteriocidal. Root resorption occurred in three cases and this has been studied by Morris (1969) who has indicated the potential of viable haemopoietic marrow to induce resorption when placed in close contact with notched root fragments. It would appear that several factors can affect the degree of resorption and clinically these must be overcome to reduce the risk (4 per cent in this series) even further, e.g.: (a) Degree ofRoot Preparation. Root planing should be minimised so that as much cementum as possible is left covering the dentine since dentine exposure would appear to potentiate resorption (Paik et al., 1971). (b) Mobility. This can be reduced by splinting during the post-operative healing period for which the use of BIS G.M.A. resins on acid etched teeth is recommended. (c) VzY.~biZity of Graft Material. Ellegaard et al. (1973) claim less root resorption using a frozen marrow material in monkey but the results are not substantiated in the human model. In view of the low incidence following this procedure it is felt that resorption should not be regarded as a deterrent for the use of fresh autogenous iliac grafts. In four cases small fragments were observed sequestrating Sequestration. through the soft tissue wound in the mucosa. One was seen during the first postoperative week and the others up to the 14 post-operative month. It was felt that these were particles of cortical material which had been included in the graft and this complication can be avoided in future by ensuring that only ‘marrow’ material is used. It is also suggested that it is better to under fill the defect to ensure adequate soft tissue cover by careful flap design. Wound healing studies by Dragoo & Sullivan (1973) have shown that true re-attachment consisting of new bone, cementum and periodontal ligament can be formed following autogenous iliac bone grafts in humans and they obtained a mean bony fill of 3.07 mm. It would seem that this simple and acceptable method of obtaining the graft material may prove to be of value to the oral surgeon in the repair of large apicectomy areas, cysts and deficient fracture and ostectomy sites and enable primary closure of the wound.

ACKNOWLEDGEMENT The author would like to acknowledge with gratitude Mr K. G. Robbins of the Photographic Department of the Bristol Dental Hospital for his help in the preparation of the photographic material.

REFERENCES DIEM, C. R., BOWERS, A. M. & MOFFITT, W. C. (1972). Journal of Periodontology, 43,295. DRAGOO, M. & IRWIN, R. K. (1972). Journal of Periodontology, 43, 82. DRAGOO, M. & SULLIVAN, H. (1973). J ournal of Periodontology, 44, 599. ELLEGAARD, B., KARRING, T. & LISTGARTEN, M. (1973). Journal of Periodontology, 44, 209. FLINT, M. (1964). British Journal of Plastic Surgery, 17, 184. HIATT, N. H. & SCHALLHORN, R. G. (1973). J ournal of Periodontology, 44, 194. MORRIS, M. L. (1969). Journal of Dental Research, 49, 180. PAIK, S., KENNEDY, J. & ZANDER, H. (1971). IADR Abstract No. 274. SCHALLHORN, R. G. (1972). Journal of Periodontology, 43, 3. 12/I-D