JICDRO is a UGC approved journal (Journal no. 63927)

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CASE REPORT
Year : 2019  |  Volume : 11  |  Issue : 1  |  Page : 36-42

Calcium sulfate: An unconventional bone graft in the management of furcation involvement – A case series


Classified Specialist, 33 CDU, C/o 99 APO

Date of Web Publication24-Jun-2019

Correspondence Address:
Dr. Mukherji Arnav
Flat 202, Block-15, Heritage Apartments, Near GC CRPF, On DBP Road, Yelahanka, Bengaluru - 560 064, Karnataka

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jicdro.jicdro_9_18

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   Abstract 


This case series is an attempt to evaluate the potentials of calcium sulfate as a regenerative modality in the treatment of furcation involvement. Conventionally, different types of alloplastic bone grafts such as demineralized freeze-dried bone allograft, freeze-dried bone allograft, beta-tricalcium phosphate (β-TCP), hydroxyapatite, bioactive glass, or a combination of these with barrier membrane have been employed. Very few studies have been carried out on human furcation involvement using calcium sulfate bone graft. The results obtained were encouraging in terms of regeneration. This case series sheds light on calcium sulfate in the management of furcal involvement.

Keywords: Calcium sulfate, regeneration, Grade III furcation


How to cite this article:
Arnav M. Calcium sulfate: An unconventional bone graft in the management of furcation involvement – A case series. J Int Clin Dent Res Organ 2019;11:36-42

How to cite this URL:
Arnav M. Calcium sulfate: An unconventional bone graft in the management of furcation involvement – A case series. J Int Clin Dent Res Organ [serial online] 2019 [cited 2019 Sep 21];11:36-42. Available from: http://www.jicdro.org/text.asp?2019/11/1/36/260955




   Introduction Top


Periodontal disease may be defined as “an inflammatory disease of the supporting tissues of the teeth caused by specific microorganisms, resulting in progressive destruction of the periodontal ligament and alveolar bone with pocket formation, recession, or both,” which is affected by age, gender, ethnicity, income, social grade, and educational status.[1] Furcation is the region of division of the tooth root. It can be a bifurcation or a trifurcation. “Furcation involvement may be defined as the invasion of the bifurcation and trifurcation of multirooted teeth by periodontal disease.”[2] Regeneration of periodontal apparatus is the hallmark of successful treatment. It is defined as the restoration of the tooth-supporting tissues, including cementum, periodontal ligament, and alveolar bone over a previously diseased root surface.[3] In the past, several techniques have been proposed to treat furcation, thereby enhancing the treatment outcome. Various regenerative procedures have been used for reducing the furcation depth.[4],[5],[6] The desire to fill a furcation defect rather than radically resecting the intact bone has invoked interest in bone replacement grafts. Bone grafting, widely used in reconstructive periodontal surgery, is a technique used to fill periodontal defects and enable regeneration of periodontal tissue.[7] The ideal bone replacement graft should be able to trigger osteogenesis, cementogenesis, and formation of a functional periodontal ligament.[8]

Many reports in the literature describe the use of calcium sulfate as a bone substitute in orthopedics. As early as 1892, Dreesmann[9] reported on the results of filling osseous defects with calcium sulfate. Peltier[10] conducted a thorough literature review of studies which described the successful filling of bone void defects with calcium sulfate materials. In author's knowledge, few studies have been conducted in treating furcation involvement using calcium sulfate. Hence, this is a unique case reporting usage of calcium sulfate as a regenerative material.


   Case Reports Top


Case 1

A 67-year-old male retired officer reported to the dental office with a chief complaint of pain in the right back region of his mouth for 4 weeks. A history of present illness confirmed incessant and throbbing pain in the said region that occasionally worsened during mastication. The patient had no relevant medical history.

The clinical assessments

The mandibular right first molar showed bleeding on probing, was highly sensitive to percussion, and showed Grade I mobility. Probing confirmed 8-mm deep periodontal pocket in 46 area [Figure 1]. Nabers probe in the furcal area demonstrated a Grade III furcation involvement [Figure 2].
Figure 1: deep periodontal pocket in relation to 46

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Figure 2: Grade III furcation involvement in 46

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The radiographic assessment

In radiographic examination, radiovisiography (RVG) confirmed Grade III furcation involvement with the evident vertical bone loss surrounding the roots [Figure 3]. Based on the clinical assessment and investigations, a systematic treatment planning was framed.
Figure 3: RVG showing vertical bone loss

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The presurgical phase

The patient signed an informed consent form after receiving information about the treatment procedure. Phase I therapy included professional plaque control, scaling, root planing, and reinforcement of the plaque control program with patient motivation and education. A clinical reevaluation after 1 month of Phase I therapy showed signs of clinical pathosis (probing depth ≥5 mm). Thus, surgical treatment was decided upon.

Surgical procedure

Following administration of a local anesthetic agent (lidocaine 2% with epinephrine 1:80,000), sulcular incision was given using a Bard-Parker blade No. 11 and extended to one tooth mesial and distal to the selected tooth [Figure 4]. Grade III furcation was evident in 46 region [Figure 5]. Granulation tissue was removed, and the root surfaces were thoroughly scaled and planed with hand and rotary instruments. A high-speed finishing bur was used to remove any enamel projections. Root biomodification was done using citric acid (ph = 1) for 1 min, with application repeated every 30 s to maintain a steady concentration of citric acid. Thereafter, calcium sulfate graft (Capset, Lifecore Biomedical, Chaska, MN, USA) was placed in the furcation region without mixing it with saline [Figure 6]. After placing the graft, collagen in gel (Bioteck Bio-Gen Gel Granules, Italy) was placed over the defect as membrane with the help of syringe [Figure 7]. The flaps were sutured with close approximation using interrupted sutures (4-0) [Figure 8]. The pack and sutures were removed after 2 weeks.
Figure 4: sulcular incision placed

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Figure 5: Grade III furcation evident

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Figure 6: calcium sulfate graft placed

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Figure 7: collagen gel placed as barrier membrane

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Figure 8: sutures placed

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Postsurgical procedure

The patient was prescribed capsule amoxicillin 500 mg thrice daily for 5 days, tablet combiflam thrice daily for 5 days, and tablet tinidazole 500 mg twice daily for 5 days. The patient was instructed on proper plaque control in all areas, except the quadrant of surgery where he was instructed not to brush. A 0.12% chlorhexidine mouthwash was prescribed for rinsing twice daily. The patient was advised to continue the chlorhexidine mouthwash for 2 weeks. After this, he was advised to start mechanical plaque control in the operated quadrant using a soft brush and roll technique. The patient was followed up regularly at 1, 3, 6, 9, and 12 months. There was no complication or adverse reaction reported. The clinical picture had improved considerably at the time of 6-month follow-up, and there was no pain or bleeding. The periodontal pocket had reduced from 8 mm to 3 mm. The RVG of the operated site after 6 months showed complete bone fill in the furcation area of 46 [Figure 9]. Clinically, the sites appeared healthy, firm, and with good adaptation to the underlying tissues.
Figure 9: complete bone fill after 6 months

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Case 2

A 33-year-old soldier reported to this dental office with pain and bleeding from the gums in the lower left back region of the jaw. A medical history was noncontributory.

The clinical assessments

The mandibular left first molar and second premolar showed bleeding on probing and deep periodontal pocket of 7 mm [Figure 10].
Figure 10: deep periodontal pocket in 35 and 36 region

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Radiographic assessment

On RVG examination, furcation area involvement was evident in 36 region [Figure 11]. In addition, intrabony defect was evident in 35 and 36 region as well.
Figure 11: RVG indicating furcation involvement in 36 region

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The presurgical phase

Phase I therapy included professional plaque control, scaling, root planing, and reinforcement of the plaque control program. A clinical reevaluation after 1 month of Phase I therapy showed persistence of probing depth ≥5 mm. Thus, surgical treatment was decided upon.

Surgical procedure

The same surgical protocol was followed as in Case 1. Grade II furcation was evident in 36 region [Figure 12]. Intrabony defect was also present in 35 region [Figure 13] Thereafter, calcium sulfate graft was placed in the furcation region as well as in intrabony defect without mixing it with saline [Figure 14]. After placing the graft, collagen in gel form was placed over the defect as membrane with the help of syringe [Figure 15]. The flaps were sutured with close approximation using interrupted sutures (4-0) [Figure 16]. Periodontal pack was applied [Figure 17]. The pack and sutures were removed after 2 weeks.
Figure 12: Grade II furcation evident in 36 region

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Figure 13: intrabony defect was present in 35 region

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Figure 14: calcium sulfate graft placed

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Figure 15: collagen gel placed

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Figure 16: sutures placed

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Figure 17: Coe-Pak placed

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Postsurgical procedure

The same postsurgical procedure was followed as in Case 1. There was no complication or adverse reaction reported. Clinically, the sites appeared healthy, firm, and with good adaptation to the underlying tissues [Figure 18]. The periodontal pocket had reduced. The RVG of the operated site showed complete bone fill in the furcation area of 36 after 6 months [Figure 19].
Figure 18: satisfactory healing in 36 region

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Figure 19: complete bone fill evident after 6 months

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   Discussion Top


There are two primary components of periodontal therapy, elimination of bacterial plaque and elimination of the anatomic defects produced by periodontitis. Resective and regenerative approaches are used for eliminating these anatomic defects. Periodontal regeneration means healing after periodontal surgery that results in the formation of new attachment apparatus which consists of new cementum, periodontal ligament, and alveolar bone. Periodontal repair takes place when healing occurs without restoration of attachment apparatus.

The treatment of furcation defects is a central component of periodontal therapy. According to a systematic review of Reddy et al.,[11] the periodontal regeneration after application of combined regenerative therapy for the treatment of mesial-buccal and distal-buccal Grade II furcation defects in the maxillary molars and buccal or lingual furcation defects in the mandibular molars is histologically proven by many studies.

Another study[12] showed that several surgical approaches for the treatment of Grade II furcation defects promote high rates of long-term survival of the multirooted teeth. The new therapies proposed for tissue regeneration aim at preventing the extraction of teeth with furcation defects and all losses associated with it. However, the indication of these therapies relies on important questions of security and cost-effectiveness to consider this treatment decision.[13]

Literature is replete with the use of calcium sulfate as a bone substitute in orthopedics. As early as 1892, Dreesmann[9] reported on the results of filling osseous defects with calcium sulfate. Sanz M[6] conducted a thorough literature review of studies which described the successful filling of bone void defects with calcium sulfate materials. Calcium sulfate was found in these studies to be generally well tolerated by tissues and resorbed. These encouraging but sometimes inconsistent results sparked additional investigation on the use of calcium sulfate as a bone graft substitute containing antibiotics to treat infected bone. The fracture zone is immobilized by its setting reaction initiated by its wetting and subsequent conversion to a strong cement-like material. Because of this immobilization, the fracture undergoes a natural healing process without any stress, which is necessary for repair of the fracture.[14]

Two parallel series of mechanisms are triggered by the degradation of calcium sulfate into deep bone defect. The first mechanism involves the release of calcium and sulfur ions in the biological environment, which results in carbonate apatite formation and calcium ion stimulation of cellular activity. The second mechanism is the precipitation of calcium phosphate, which leads to a transient local drop in pH. This causes surface demineralization of existing bone resulting in exposure of bioactive molecules and the release of growth factors such as transforming growth factors and bone morphogenetic proteins, which stimulates the growth of bone in defects filled with calcium sulphate.[15]

Horowitz et al.[16] demonstrated the use of β-TCP alone or in combination with calcium sulfate as predictable materials for maintenance and/or enhancement of bone volume after tooth extraction.

A study demonstrated that the treatment with a combination of β-TCP and calcium sulfate led to a significantly favorable clinical improvement in periodontal intrabony defects 2 years after the surgery.[17] Another surgical case reported[18] that medical-grade calcium sulfate when mixed with demineralized freeze-dried bone allograft was found to be a biocompatible composite graft with the ability to provide radiographic evidence of hard-tissue repair of a periodontal intrabony defect.

Setya and Bissada[19] clinically evaluated the effectiveness of a composite graft, consisting of demineralized freeze-dried bone and doxycycline hyclate (4:1 by volume) in combination with a resorbable calcium sulfate barrier in the treatment of Grade III furcation involvement. The author concluded that combined composite graft and resorbable barrier utilized in this study have a favorable effect on the treatment outcome of mandibular Grade III furcations 12 months postoperatively when compared to surgical debridement only.

In a study, Maragos et al.[20] compared the effectiveness of three methods using calcium sulfate as a graft/barrier for the treatment of Grade II mandibular furcation defects. The results showed significant bone fill, vertical and horizontal probing depth reduction, defect volume reduction, and a gain in vertical clinical attachment.

This clinical study[21] compared the bone regeneration capacity of a commonly used GTR procedure (demineralized freeze-dried bone allograft [DFDBA] and an expanded polytetrafluoroethylene [ePTFE] membrane to DFDBA and an exclusion barrier of medical-grade calcium sulfate hemihydrate [MGCSH]). Improved clinical measurements were achieved with DFDBA/MGCSH as well as DFDBA/ePTFE. Both treatments obtained significant horizontal defect fill at 6 months. DFDBA/ePTFE showed a significantly greater horizontal defect fill compared to DFDBA/MGCSH. Attachment level gains achieved with MGCSH held for 12 months, whereas ePTFE attachment level gains did not.


   Conclusion Top


In light of the findings, it was demonstrated that the calcium sulfate graft used in the management of furcation involvement represents a promising way to get a better clinical situation with a more predictable amount of regeneration. It represents also an alternative to other conventionally used bone grafts so far used.

Acknowledgment

I would like to thank Col (Retd) MK Mukherji, Mrs S Mukherji, and Dr. Siddharth Mukherji for their valuable support. This study has not been funded by any organization.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Novak MJ. Classification of diseases and conditions affecting the periodontium. In: Newman MG, Takei HH, Klokkevold PR, Carranza FA, editors. Carranza's Clinical Periodontology. 10th ed. Missouri: WB Saunders Co.; 2009. p. 103.  Back to cited text no. 1
    
2.
Carranza FA. Bone loss and patterns of bone destruction. In: Newman MG, Takei HH, Klokkevold PR, Carranza FA, editors. Carranza's Clinical Periodontology. 10th ed. Missouri: WB Saunders Co.; 2009. p. 462.  Back to cited text no. 2
    
3.
Nevins ML, Camelo M, Nevins M, King CJ, Oringer RJ, Schenk RK, et al. Human histologic evaluation of bioactive ceramic in the treatment of periodontal osseous defects. Int J Periodontics Restorative Dent 2000;20:458-67.  Back to cited text no. 3
    
4.
Evans GH, Yukna RA, Cambre KM, Gardiner DL. Clinical regeneration with guided tissue barriers. Curr Opin Periodontol 1997;4:75-81.  Back to cited text no. 4
    
5.
Garrett S. Periodontal regeneration around natural teeth. Ann Periodontol 1996;1:621-66.  Back to cited text no. 5
    
6.
Sanz M, Giovannoli JL. Focus on furcation defects: Guided tissue regeneration. Periodontol 2000 2000;22:169-89.  Back to cited text no. 6
    
7.
Carranza FA, Takei HH, Cochran DL. Reconstructive periodontal surgery. In: Newman MG, Takei HH, Klokkevold PR, Carranza FA, editors. Clinical Periodontology. 10th ed. Missouri: Saunders Co.; 2006. p. 968-90.  Back to cited text no. 7
    
8.
Nasr HF, Aichelmann-Reidy ME, Yukna RA. Bone and bone substitutes. Periodontol 2000 1999;19:74-86.  Back to cited text no. 8
    
9.
Dreesmann H: Ueber Knochenplombierung. Beitr Klin Chir 1892;9:804-10.  Back to cited text no. 9
    
10.
Peltier LF. The use of plaster of Paris to fill large defects in bone. Am J Surg 1959;97:311-5.  Back to cited text no. 10
    
11.
Reddy MS, Aichelmann-Reidy ME, Avila-Ortiz G, Klokkevold PR, Murphy KG, Rosen PS, et al. Periodontal regeneration – Furcation defects: A consensus report from the AAP regeneration workshop. J Periodontol 2015;86:S131-3.  Back to cited text no. 11
    
12.
Huynh-Ba G, Kuonen P, Hofer D, Schmid J, Lang NP, Salvi GE, et al. The effect of periodontal therapy on the survival rate and incidence of complications of multirooted teeth with furcation involvement after an observation period of at least 5 years: A systematic review. J Clin Periodontol 2009;36:164-76.  Back to cited text no. 12
    
13.
Lin Z, Rios HF, Cochran DL. Emerging regenerative approaches for periodontal reconstruction: A systematic review from the AAP regeneration workshop. J Periodontol 2015;86:S134-52.  Back to cited text no. 13
    
14.
Thomas MV, Puleo DA, Al-Sabbagh M. Calcium sulfate: A review. J Long Term Eff Med Implants 2005;15:599-607.  Back to cited text no. 14
    
15.
Dumitrescu AL. Chemicals in Surgical Periodontal Therapy. Norway: Springer; 2011. p. 115-6.  Back to cited text no. 15
    
16.
Horowitz RA, Rohrer MD, Prasad HS, Mazor Z. Enhancing extraction socket therapy. The J Implant Adv Clin Dent 2009;1:47-58.  Back to cited text no. 16
    
17.
Sukumar S, Drízhal I, Paulusová V, Bukac J. Surgical treatment of periodontal intrabony defects with calcium sulphate in combination with beta-tricalcium phosphate: Clinical observations two years post-surgery. Acta Medica (Hradec Kralove) 2011;54:13-20.  Back to cited text no. 17
    
18.
Mazor Z, Mamidwar S, Ricci JL, Tovar NM. Bone repair in periodontal defect using a composite of allograft and calcium sulfate (DentoGen) and a calcium sulfate barrier. J Oral Implantol 2011;37:287-92.  Back to cited text no. 18
    
19.
Setya AB, Bissada NF. Clinical evaluation of the use of calcium sulfate in regenerative periodontal surgery for the treatment of class III furcation involvement. Periodontal Clin Investig 1999;21:5-14.  Back to cited text no. 19
    
20.
Maragos P, Bissada NF, Wang R, Cole BP. Comparison of three methods using calcium sulfate as a graft/barrier material for the treatment of class II mandibular molar furcation defects. Int J Periodontics Restorative Dent 2002;22:493-501.  Back to cited text no. 20
    
21.
Couri CJ, Maze GI, Hinkson DW, Collins BH 3rd, Dawson DV. Medical grade calcium sulfate hemihydrate versus expanded polytetrafluoroethylene in the treatment of mandibular class II furcations. J Periodontol 2002;73:1352-9.  Back to cited text no. 21
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19]



 

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