DR.

FRANK BRÖSELER (Orcid ID : 0000-0002-5146-5452)

PROF. SØREN JEPSEN (Orcid ID : 0000-0002-4160-5837)

Accepted Article
Received Date : 06-Aug-2016

Revised Date : 23-Feb-2017

Accepted Date : 12-Mar-2017

Article type : Case Report or Case Series

Long-term results of periodontal regenerative therapy: a retrospective practice-based

cohort study

Frank Bröseler 1*, Christina Tietmann 1*,

1
Private Practice for Periodontology, Aachen, Germany

*Both authors contributed equally

Ann-Katrin Hinz 2,

2
Private Practice, Hattingen, Germany

Søren Jepsen 3,
3
Dept. of Periodontology, Operative and Preventive Dentistry,

University of Bonn, Germany

Running Title: Practice long-term regenerative results

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/jcpe.12723
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 Keywords: regenerative periodontal therapy, radiographic bone level, bovine bone mineral,

membrane, collagen, enamel matrix protein, long-term, compliance

Accepted Article
Corresponding Author: Dr. Frank Bröseler, Krefelder Str. 73, D-52070 Aachen,

Tel: +49 241 918450, Fax: +49 241 9184521, E-mail: praxis@paro-aachen.de

Conflict of Interest and Sources of Funding Statement

The authors declare to have no conflict of interest. The analysis by an independent statistician

was supported by a grant from the company Geistlich, CH. The authors had full control of the

data at all times. No other external funding, apart from the support of the authors´ institution,

was available for this study.

Abstract

Aim: Evaluation of the long-term effectiveness of regenerative treatment of intrabony defects

in periodontal practice.

Material and Methods: A total of 1008 intrabony defects in 176 patients were analyzed after

using collagen-added deproteinized bovine bone mineral (DBBMc) with or without collagen

membrane (CM) or enamel matrix derivative (EMD). Defects were classified as 1- and 2-wall

and as shallow (≤ 6 mm), moderate (> 6 and < 11 mm) and deep (≥11 mm). Radiographic

bone level changes were evaluated after 1 year, 2 to 4 years and 5 to 10 years.

Results: Mean radiographic defect fill was 3.8 mm after 1 year and remained stable up to 10

years. Deep and moderate defects showed a higher degree of fill than shallow defects (53.3%,

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 49.2%, 42.9%). Tooth loss amounted to 2.6%, was dependent on initial defect size (1.2%

shallow, 1.4% moderate, 5.7% deep defects) and occurred mainly due to endodontic reasons.
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Conclusions: Within the limits of the retrospective study design, the findings indicate that

periodontal treatment using DBBMc with or without CM or EMD can lead to long-term

defect reduction and tooth survival for up to 10 years in the setting of a periodontal practice.

Clinical Relevance

Scientific rationale for the study: While numerous randomized clinical trials have

demonstrated that regenerative therapies may effectively be used for the treatment of

periodontal intrabony defects, long-term results with large numbers of teeth in patient

populations as seen in daily practice are rarely reported.

Principal findings: In this retrospective cohort study significant radiographic bone fill was

observed, that was stable for up to 10 years.

Practical implications: The results indicate that in the setting of a specialized practice even

periodontally severely compromised teeth may be treated successfully and maintained with a

good long-term prognosis, given an adequate oral hygiene and patient compliance.

Introduction

Various techniques such as the use of bone substitutes, enamel matrix derivative (EMD) and

barrier membranes (guided tissue regeneration, GTR) as well as combinations of these have

been evaluated in clinical studies (Brunsvold and Mellonig 1993, Jepsen et al. 2008, Meyle et

al. 2011, Sculean et al. 2003, Sculean et al. 2008a, Sculean et al. 2008b, Sculean et al. 2008c,

Trombelli and Farina 2008, Trombelli et al. 2002, Wang et al. 2005, Yukna and Mellonig

2000).

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 Among the bone substitutes, deproteinized bovine bone mineral (DBBM) has shown

favorable results in clinical or histological studies when used alone (Gokhale and
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Dwarakanath 2012), in combination with a collagen membrane (Camargo et al. 2000, Camelo

et al. 2001, Camelo et al. 1998, Mellonig 2000), as collagen-enriched bone mineral (DBBMc)

used alone (Cosyn et al. 2012, Nevins et al. 2003) or in combination with bioresorbable

membranes (Hartman et al. 2004, Nevins et al. 2003) or as DBBM combined with the use of

EMD (Iorio-Siciliano et al. 2014, Lekovic et al. 2000, Sculean et al. 2008a, Velasquez-Plata

et al. 2002, Zucchelli et al. 2003). Membranes may contribute to wound stabilization and

containment of graft particles (Haney et al. 1993, Hartman et al. 2004). Bone substitutes have

also been combined with EMD in order to enhance periodontal regeneration (Tu et al. 2010).

In particular the combination of DBBM with EMD led to superior outcomes (Velasquez-Plata

et al. 2002, Zucchelli et al. 2003). In addition, in vitro and in vivo studies have indicated a

positive effect of EMD on wound healing by promoting angiogenesis and epithelial healing

(Al-Hezaimi et al. 2012, Kasaj et al. 2012, Nokhbehsaim et al. 2011).

Although periodontitis patients may benefit from combination therapies, the cost-benefit

relation has to be considered, especially in a private practice and when patients finance the

therapies by themselves. Therefore, in the authors’ practice a treatment algorithm has been

established that aims to account for both: results from scientific studies as well as cost

effectiveness (Bröseler and Tietmann 2007). According to this algorithm the following

treatment modalities are applied:

a) In severe intrabony defects deproteinized bovine bone mineral with collagen (DBBMc) is

applied as a filler.

b) In non-contained defects bioresorbable collagen membranes (CM) are used to cover and

stabilize the graft.

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 c) In defects with soft tissue deficiencies EMD is applied to support wound healing.
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While periodontally compromised teeth may be successfully treated and maintained in the

long term (Donos et al. 2012) the result of a therapy is strongly influenced by various patient

factors: Compliance with the recall program including regular follow-up controls and

professional dental hygiene has been shown to be of high importance (Checchi et al. 2002,

Cortellini et al. 1994, Cortellini and Tonetti 2004, Franke et al. 2015, Nygaard-Ostby et al.

2010, Sculean et al. 2008b, Silvestri et al. 2011). Regenerative periodontal therapies may be

less effective in smokers, since smoking has been associated with compromised wound

healing, longer healing times and reduced gain in CAL (Silvestri et al. 2011, Tonetti et al.

1995).

In order to control for possible confounders and to reduce bias, in randomized controlled

trials a stringent patient selection is required.

The aim of this retrospective study was to evaluate the long-term effectiveness of periodontal

regenerative therapy of up to ten years in a private periodontal practice in a large number of

patients and teeth in the non-selected, day-to-day patient population.

Materials and Methods

Patients

A total of 255 patients who had presented with moderate to severe chronic periodontitis in a

periodontal specialty practice (FB and CT) in Aachen, Germany, were available for a

retrospective analysis of the outcomes of regenerative therapy. In the period of 2000 to 2008,

a total of 1530 teeth with one- or two-wall intrabony defects had been consecutively treated.

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 The study was conducted in accordance with the Helsinki Declaration (version 2008) and the

Ethical committee of the University of Bonn was notified. Patients gave their written
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informed consent for a retrospective evaluation of their clinical and radiographic data.

Patients were included into the analysis when data from at least the 2-year examination after

surgery was available. Smokers, patients with systemic diseases (i.e. controlled diabetes or

cardiovascular disease with or without related medication) were not excluded from the

evaluation.

Criteria to exclude patients from the analysis were:

- loss to follow-up

- missing recall data due to non-compliance

- incomplete data such as missing probing or radiographic recordings (i.e. patients

rejecting permission to take follow-up radiographs)

- additional orthodontic treatment

- additional periodontal or maxillofacial procedures

According to the criteria above a total of 176 patients with 1008 intrabony defects could be

included into analysis.

Treatment

Patients had undergone non-surgical anti-antiinfective therapy including oral hygiene

instructions and control. No antibiotics were administered during this initial therapeutical

stage that was performed by a trained dental hygienist. At re-evaluation, if clinical parameters

did not show improvement despite of good patient compliance or if aggressive periodontitis

was diagnosed or if the defects still presented with suppuration, subgingival plaque samples

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 were obtained and a microbiological analysis was performed (micro-IDent®, Hain

Diagnostics, Nehren, Germany). If elevated levels (> 104) of periodontopathogens were

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detected systemic antibiotic therapy was prescribed. As standard medication a combination of

amoxicillin and metronidazole was administered, and in case of penicillin allergy,

levofloxacin or ciprofloxacin were used.

Patients were surgically treated by one of two experienced periodontists (FB and CT). Under

local anesthesia, intra-crevicular incisions maintaining the papillae or basal split flap

preparation was performed for access using a microsurgery blade (SM69, Swann-Morton ltd.,

Sheffield, UK). Vertical releasing incisions were performed when necessary, e. g. for

improving the visibility of the surgical area or to enable tension free adaptation of the flap

while suturing. Hand instruments and rotating instruments were used for removal of

granulation tissue. Curettes and an ultrasonic device (Cavitron/Slimline, DENTSPLY,

Konstanz, Germany) were used for debridement and rotating instruments (Desmo-Clean®,

Komet, Lemgo, Germany or Finishing Diamond #4310S, Perio Set®,Intensiv SA,

Montagnola, Switzerland) for root planing. The intrabony defects were filled with

deproteinized bovine bone mineral with collagen (DBBMc, Bio-Oss® Collagen, Geistlich,

Wolhusen, Switzerland). If the surgeon considered the graft material to be at risk to get

dislocated from non-contained defects, a collagen membrane (Bio-Gide®Perio, Geistlich,

Wolhusen, Switzerland) was applied without suture or pin fixation. The flap was repositioned

without tension. In about 10% of the defects, where soft tissue quality was judged as

compromised intraoperatively by the surgeon, enamel matrix derivative (EMD, Emdogain®,

Straumann, Basel, Switzerland) was applied adjunctively to DBBMc or DBBMc + CM, in

order to enhance early epithelial wound healing. Teeth with mobility >1 (O'Leary 1969) were

temporarily splinted to stabilize the blood clot and the graft. Modified horizontal mattress

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 sutures were used to close releasing incisions and to adapt papillae (6-0 Monofilament single

sutures Premilene® USP6/0-DS13, B.Braun, Tuttlingen, Germany; Seralene® USP6/0-DS12,

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SeragWiessner, Naila, Germany; Seralene® USP6/0-DS15, SeragWiessner, Naila, Germany).

Postoperatively, the patients were instructed to rinse with 0.2% chlorhexidine solution three

times per day for four weeks or until complete soft tissue healing. Patients were not allowed

to perform mechanical interdental tooth cleaning in the surgical area until soft tissues were

re-keratinized. Sutures were removed after 10 to 14 days, depending on individual wound

healing progression.

During the first 6 months after surgery, patients were followed in a tight recall system

beginning with 4 week intervals, according to the practice standard protocol, up to 3 months

postoperatively. Subsequently patients were recalled for hygiene reinforcement and healing

was monitored every 6 weeks (up to 6 months post -op), every 8-12 weeks (up to 12 months

post-op), every 3 months (up to 2 years post-op) and thereafter every 6 months or according

to their individual needs. In the surgical area professional tooth cleaning was performed

without further subgingival instrumentation during the first six postoperative months. If there

were sites with residual PPD >5 mm at 1 year post-op or later, these sites were maintained

with higher than normal intensity, including regular subgingival debridement.

Clinical Measurements

Probing pocket depth (PPD) was measured pre-operatively at 4 sites per tooth. In addition, a

preoperative radiograph was obtained. Intraoperatively, the bone level (BL) was measured

using a probe (PCP11, Hu-Friedy, Leimen, Germany) parallel to the long axis of the tooth.

BL was defined as the distance between the cemento-enamel junction and the deepest part of

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 the intrabony defect. In case the cemento-enamel junction could not be identified because of

restorations, the restoration margin was used as reference point. If more than one site of a
Accepted Article
tooth presented with identical BL measurement height, the site with the deepest preoperative

PPD was chosen for follow-up evaluation.

The intraoperative BL measured by clinical probing was used to calibrate the preoperative

radiograph. Radiographs were taken by the use of a long-cone parallel technique using film

holders (HAWE Super-bite Senso, Kerr GmbH, Rastatt, Germany), in order to allow for a

parallel orientation (3x4 cm single tooth F-speed films, Kodak, Germany, using Dürr

Periomat plus or Dürr XR24 developing machine, Dürr Dental AG, Bietigheim-Bissingen,

Germany). After digitizing the radiographs (Digital camera Casio EX-Z40, Casio Computer

Co., LTD Tokyo, Japan), they could be analyzed (ImageJ Software Version 1.44o, National

Institutes of Health, Bethesda, MD, USA). The clinically determined BL was marked on the

preoperative radiograph to obtain the reference distance. For calibration and to allow

comparison with subsequent radiographs, the overall tooth length was used (Fig. 1).

All radiographs were analyzed by a trained and calibrated examiner who was not involved in

the surgeries.

One year after surgery, complete clinical and radiographic data were recorded. PPD was

recorded every year during the regular maintenance treatment. Radiographic BL was

determined after 1 year, after 2 – 4 years, and after 5 - 10 years.

Analysis

Change in radiographic bone level (BL) was the primary outcome parameter, whereas

changes in PPD served as secondary outcomes.

The following evaluation time points/periods were defined:

t0 – time of regenerative surgery (baseline)

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 t1 – 1 year post-op

t2 – mid-term follow-up (2 – 4 years)

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t3 – long-term follow- up (5-10 years)

For t2 and t3 the data measured at the longest post-op observation time point within this time

frame were chosen for each patient. Means for t2 were 3.3 ± 0.7 years for BL, 3.8 ± 0.5 years

for PPD, and for t3 6.4 ± 1.3 years for BL, 6.2 ±1.4 years for PPD.

Data was evaluated for all teeth as well as per patient (means). For the teeth for which data

was available at all three observation time points, the change over time was analyzed on tooth

and patient level. In addition, the change over time was evaluated for the most severe defect

per patient.

Statistical analysis

The analysis was performed using R version 2.13.0 (The R Foundation for Statistical

Computing). Numeric variables such as certain patient characteristics and endpoints

(radiographic bone level, PPD and their changes over time) are summarized by means and

standard deviations. Categorical information is presented by providing absolute and/or

relative counts. If not clear from the context, in the text it is mentioned whether these

numbers relate to patients or defects as observational units.

To test for gains of radiographic bone level and reductions of PPD over time, a version of

Wilcoxon's signed rank test for clustered data (Rosner et al. 2006) is applied to account for

intrapatient correlations. All p-values belong to two-tailed tests and are of purely exploratory

nature. The level of significance of each test was set to 0.05.

In addition a repeated measures linear mixed effects model for the response “radiographic

bone fill in mm” was applied in order to investigate the response profile over time and

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 treatment, taking into consideration the potential confounders “baseline radiographic bone

level”, “smoking”, and the number of defect walls. The variance/covariance structure was
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chosen to account for two levels of dependencies between records: defects and repeated

measures. This was modelled using random patient intercepts, and nested within patient,

random defect intercepts. After consultation of diagnostic plots of residuals and of best linear

unbiased predictions of the two levels of random effects, both response and the covariable

representing with baseline radiographic bone fill were log transformed. p-values associated

with fixed model parameters were calculated based on Satterthwaite's approximations of the

degrees of freedom on the 5% level.

Subgroup analysis

Defects were classified based on their baseline morphology determined during surgery as 1-

and 2-wall defects and (measured by clinical probing from BL to CEJ) as shallow (≤ 6 mm),

moderate (> 6 mm and < 11 mm) and deep (≥11 mm). These subgroups were compared to

each other regarding change in radiographic bone level over time. In additional subgroup

analyses, the radiographic bone level changes in smokers and non-smokers, in single-rooted

or multi-rooted teeth and for the different treatment modalities were compared to each other.

Results

Patient and defect characteristics

Of the total of 255 patients treated, 79 patients (with 522 teeth) were excluded from the

evaluation because of the following reasons: 37 patients (with 335 teeth) underwent

additional orthodontic treatment, in 32 patients (135 teeth) complete follow up data were

missing due to non-compliance, 4 patients (with 11 teeth) presented with furcations class III,

2 patients (with 14 teeth) underwent additional maxillofacial surgical procedures, 4 patients

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 (with 27 teeth) were lost to follow-up due to personal reasons (death, severe medical

conditions, moving to another city).

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Compliance was defined as previously described (Franke et al. 2015):

C0: Patients who failed to attend more than two scheduled appointments within the first two

years of SPT or did not comply with SPT appointments for more than two years during

follow-up period were classified as non-compliant. These patients were not included in the

study.

C1: patients who attended SPT as scheduled at any time during the observation period, as C2:

patients who missed at least one appointment in at least one year of ongoing SPT, but were

not more than one year without SPT.

Finally, 176 patients with a total of 1008 intrabony defects were included into the analysis.

The number of defects per patient ranged from 1 to 21 defects with an average of 5.73.

Overall, 26.5% of the sites were one-wall, 73.5% were two-wall defects. At baseline, mean

radiographic BL was 8.14 ± 1.98 mm (4.29 – 15.0 mm).

An overview on patient and defect characteristics is presented in Tab. 1

DBBMc alone was used in 39.98% of the defects (26.22% for one-wall defects / 44.94% for

two-wall defects), whereas in 50.00% of the defects DBBMc+CM was applied (63.29% for

one-wall defects / 45.21% for two-wall defects). DBBMc+EMD was used in 6.15% (3.75%

for one-wall defects / 7.02% for two-wall defects), and DBBMc+CM+EMD in 3.87% of the

defects (6.74% for one-wall defects / 2.83% for two-wall defects).

Postoperative Findings

Soft tissue healing was usually uneventful. There were no allergic reactions, suppuration or

abscesses. Minor complications such as postoperative swelling and pain in the surgical area

disappeared within a few days after surgery. Membrane exposures were rare. They have been

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 documented in 21 cases (21 teeth, 11 patients). In such cases, the membranes were left in

place and controlled more frequently. Intensive chemical plaque control was performed,
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using 0.2% chlorhexidine mouth rinse solution (recommended 4 times per day). All exposed

sites healed without any further complications.

Tooth loss amounted to 2.6% (27 teeth in 19 patients), was dependent on initial defect size

(1.2% for shallow, 1.4% for moderate, 5.7% for deep defects) and occurred in about 50% of

the cases due to late endodontic problems.

Radiographic bone level was determined in 176 patients with 1008 teeth at baseline and after

1 year, in 123 patients with 619 teeth at t2 (3.30 ± 0.70 years) and in 53 patients with 226

teeth at t3 (6.4 ± 1.3 years).

The repeated measures linear mixed effects models for the response “radiographic bone fill in

mm” revealed that significant factors (at the 5% level) with positive effect on the response

profile were time and number of defect walls while a factor with negative significant effects

was deep baseline defects (Table 2).

When analyzing the change of radiographic BL over time in 226 teeth for which data were

available at all time points, there was a significant gain in radiographic bone level after 1 year

from 7.62 ± 2.21 to 4.09 ±1.47 mm (p < 0.001), a further gain from t1 to t2 to 3.63 ± 1.39mm

(p < 0.001) that remained stable until t3: 3.72 ± 1.58mm (Tab. 3). The same applied when

data were aggregated to means per patient and when only the deepest defect per patient was

analyzed (Tab. 3). The highest defect fill was achieved for deep defects (53.3% vs. 49.2% for

moderate and 42.9% for shallow defects). Bone level changes were very similar when

comparing the following different subgroups to each other: smokers and non-smokers (Fig.

2a), one- or two-wall defects (Fig. 2b), single- or multi-rooted teeth (Fig. 2c) and the different

treatment modalities (Fig. 2d).

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 Mean PPD was recorded in 1008 teeth at baseline (5,82 ± 2.02.mm), 963 teeth at t1 (3.37 ±

1.3 mm), in 857 teeth at t2 (3.36 ± 1.41. mm) and in 378 teeth at t3 (3.54 ± 1.57 mm). The
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frequency distribution of residual defects (BL) and probing depths (PPD) for the subsample

that attended all visits from baseline to t3 is presented in Tab. 4.

When analyzing the data for possible associations between different factors and under

consideration of the other variables, radiographic bone gain was found to be 13% higher in

deep defects and 8.4% higher in moderate defects when compared to shallow defects (p <

0.05).

Discussion

This retrospective clinical cohort study was performed to evaluate the long-term effectiveness

of regenerative periodontal therapy over up to ten years from a patient population in the

setting of a typical private periodontal practice.

The results demonstrated that deproteinized bovine bone mineral with collagen alone or in

combination with a collagen membrane or enamel matrix derivative may successfully be used

to treat one- or two-wall intrabony periodontal defects in single- and multi-rooted teeth. The

radiographic bone level was significantly improved and remained stable over the observation

period of up to ten years. A higher amount of radiographic bone gain was observed in deep

defects. Probing pocket depths were significantly reduced and remained shallow.

The observed mean radiographic bone level gain of 3.8 mm in the present study compares

well with the 3.2/3.0 mm gain after 6 months reported in a previous study using DBBM with

or without EMD (Scheyer et al. 2002), however was less than the mean bone gain of 5.3 mm

observed 12 months after application of DBBM and EMD (Zucchelli et al. 2003). The

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 outcomes of the present study were also somewhat inferior to the mean bone gain of 4.7mm

following DBBM and GTR reported in a case series (Stavropoulos and Karring 2005).
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In order to put these improvements in bone level following regenerative therapy into

perspective, they have to be compared to the outcomes after access flap surgery. In a

systematic review with meta-analysis the mean radiological bone gain at 12 months

amounted to 0.95 mm (95%CI: 0.62, 1.28) (Graziani et al. 2012). These results are in contrast

to a very recent retrospective analysis of a minimally invasive non-surgical approach, where a

mean radiographic bone gain of 2.4 mm was found at 12 months (Nibali et al. 2015).

Stable long-term results for regenerative periodontal therapy using DBBM, as observed by

the present analysis, were also reported in other studies. When using DBBM and CM for the

treatment of deep intrabony defects in 19 patients a significant reduction of mean CAL from

10.4 ± 1.3 mm at baseline to 6.7 ± 1.6 mm was observed after 5 years (Sculean et al. 2007).

In a second study, the authors demonstrated successful periodontal regeneration in intrabony

defects using DBBM + EMD in 11 patients over a period of 5 years (Sculean et al. 2008a). A

significant clinical attachment gain was also achieved and maintained over 6 years in

intrabony defects in a study performing GTR vs. GTR+DBBM (Stavropoulos and Karring

2010). Clinical improvements obtained with regenerative surgery using EMD + DBBM or

EMD + beta-TCP could be maintained over a period of 10 years (Dori et al. 2013). In a

systematic review on periodontal regeneration in intrabony defects it was concluded that

improvements in clinical parameters are maintainable up to 10 years, consistent with a

favorable long-term prognosis (Kao et al. 2015). A recent study reported clinical stability of

sites treated with regeneration compared to OFD after 20 years (Cortellini et al. 2016).

The treatment modalities performed in the present group of patients were chosen based on the

empirically developed treatment algorithm used in the practice. Although these different

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 treatment combinations have been tested in various studies, comparative data are scarce and

this treatment algorithm is not supported by evidence from systematic reviews, and clear
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recommendations on when to use one of the modalities are still missing. However, in clinical

practice periodontists need to balance the costs for therapies and their proven or assumed

benefit to find the best and most predictable therapeutic solution for their patients. It is hoped

that the initially higher costs of regenerative procedures will pay off by higher tooth retention

and less periodontitis progression, as it was recently demonstrated and discussed by Cortellini

et al. (2016). In the present study, all four treatment modalities allowed adequate defect

resolution and stable long-term results which indicates that the treatments are effective when

applied according to the treatment algorithm used.

The analyses for associations between different factors demonstrated significant associations

between BL changes over time and initial defect size. This indicates that more bone gain is

achieved in deeper defects confirming earlier reports from clinical trials (Falk et al. 1997,

Linares et al. 2006). No associations were found between BL changes and the type of tooth

(single- versus multi-rooted).

The overall tooth survival rate in the reported cohort was 97.4%. Teeth were mainly lost due

to late endodontic problems. The data did not indicate any association between the initial

bone level and tooth survival. Other groups have also reported high tooth survival rates in

periodontally compromised teeth if maintenance was adequate (Cortellini and Tonetti 2015).

Cortellini and Tonetti (2004) performed a Kaplan-Meier analysis of tooth survival following

periodontal-regenerative treatment in a sample of 175 patients followed up for 2-16 years in a

specialist environment. In this study, 96% of teeth treated by periodontal regeneration

survived. In a randomized controlled clinical trial in 50 patients with hopeless teeth due to

severe intrabony defects, the long-term results of periodontal regeneration or extraction and

prosthetic replacement of teeth were compared (Cortellini et al. 2011). Of the teeth

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 undergoing regenerative therapy, 92% survived and were in function after 5 years. The

authors concluded that regenerative periodontal treatment can change the prognosis of teeth
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appraised hopeless and may be an appropriate alternative to extraction. A review confirmed

that regenerative therapy may arrest disease progression and minimize or prevent tooth loss if

patients are enrolled in an efficient maintenance program (Donos et al. 2012). However, the

authors emphasized that patient expectations regarding the final treatment outcome need to be

considered when deciding on treating or extracting periodontally compromised teeth. A

recent evaluation of patient’s perception after long-term systematic periodontal treatment

revealed high positive ratings of performed regenerative periodontal treatment (Franke et al.

2015).

In the present cohort, smokers were not excluded. While smoking is a well-known risk factor

for the outcomes of periodontal treatment (Genco and Borgnakke 2013, Patel et al. 2012), no

significant effect of smoking on the change of BL was found here. This is in line with the

findings of Tonetti and coworkers (Tonetti et al. 2004). BL measured after one year remained

stable over the complete observation period both for smokers and non-smokers and thus no

significant association was found between the gain in bone level and smoking. In contrast,

findings of a former controlled study demonstrated that smoking yielded significantly less

periodontal attachment gain after regenerative procedure using non-resorbable membranes

(Tonetti et al. 1995). However, the authors described that the level of oral hygiene

determined the risk. In the study presented here, all patients were included in a strict and

individualized maintenance program. This may have compensated for the possible negative

effect of smoking. However, the present data should not be interpreted to advocate

regenerative therapy in smokers and further studies are needed to investigate this issue.

The study analyzed the outcome of regenerative periodontal therapy in patients in the

environment of a private periodontal practice and included a total of 176 patients and 1008

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 teeth over an observation period of up to 10 years. While the comparatively large patient

number, long observation time and settings of a private practice are advantages for the
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generalizability of the results of this study, the analysis has also some limitations: The

treatment modality was chosen depending on the defect morphology and soft tissue situation.

No randomization was performed. Therefore it is hardly possible to compare the efficacy of

the different treatment modalities to each other. In addition, the number of sites per patient

varied which may have resulted in a possible bias due to intra-patient dependencies, and the

available data decreased from t1 to t3. To compensate for these possible limitations, additional

statistical tests were run using adequate models. However, the results of this study including

subgroup analyses of treatment modalities should be interpreted with caution, and further

prospective randomized controlled studies are necessary to confirm the results.

The radiographic evaluation performed in the present study had to rely on radiographs that

were obtained in a standardized fashion using a long cone paralleling technique, however no

customized film holders were used to permit an even higher reproducibility.

Many previous studies have employed radiographic methods to assess the outcome of surgery

(Eickholz et al. 1998, Tonetti et al. 1993, Persson et al. 2000, Linares et al. 2006). Very often

radiographs were standardized by using Rinn holders, as it was done in the present study.

Measurement errors may exist due to the fact that no customized film holder stents were

used, however we compensated for the possible distortion between sets of radiographs by

calculation of the ratios of root length from baseline and follow-up radiographs. This ratio

was used to correct post-treatment linear measurements of bone changes (Tonetti et al. 1993).

Furthermore, a radio-opaque bone filler was used, which does not allow to discern graft from

newly regenerated bone. Based on human histological studies, however, it is assumed that the

biomaterial applied can promote periodontal regeneration (Sculean et al. 2015).

This article is protected by copyright. All rights reserved.

 In summary, within the given limitations of a retrospective study design, the results indicate

that even periodontally compromized teeth with severe vertical bone loss may be treated
Accepted Article
successfully using DBBMc with or without CM or EMD. In the setting of a private specialty

practice such teeth may be maintained with a good long-term prognosis, given an adequate

patient compliance.

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Accepted Article
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Acknowledgements

We thank Dr. Michael Mayer, Bern/Switzerland, for his expert statistical analysis.

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 Table and Figure Legends

Table 1: Patient and defect characteristics at baseline

Accepted Article
Table 2: Results of repeated measures linear mixed effects model for the response

“radiographic bone fill in mm”

Table 3: Mean radiographic bone level (BL) ± standard deviation (mm) over time calculated

for patients and teeth with different length of follow-up. Means for t2 (2 – 4 years) were 3.3 ±

0.7 years and for t3 (5 – 10 years) 6.4 ± 1.3 years. Analysis on the level of teeth, patient and

deepest defect per patient.

Table 4: Frequency distribution of residual BL and PPD for the subsample that attended all

visits from baseline to t3.

Figure 1

a) Calibration after digitization of baseline (t0) radiographic image: measured distance

from CEJ to bottom of defect

b) Follow-up radiographic image at 1 year (t1)

c) Follow-up radiographic image at 2-4 years (t2)

d) Follow-up radiographic image at 5-10 years (t3)

Figure 2

Changes in bone level (BL) over time comparing different subgroups (mean ± SD):

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 a) smokers vs non-smokers

b) defect morphology: one- or two-wall and small, moderate or deep

Accepted Article
c) teeth with one roots vs two or more roots

d) treatment modality: Deproteinized Bovine Bone Mineral Collagen (DBBMc),

DBBMc + Collagen Membrane (CM), DBBMc + Enamel Matrix Derivative

(EMD), DBBMc + CM + EMD (for DBBMc+EMD no long-term data were

available)

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 Table 1: Patient and defect characteristics at baseline

Patient and Defect Characteristics at baseline

Accepted Article
N patients 176
N teeth 1008

Female gender 54.4%

Age at baseline 49.9 (26-77)
Smokers 25%

single-rooted 527 / 52,3%

multi-rooted 481 / 47.7%
defect 'shallow' ≤ 6 mm 310 / 30.8%
defect 'moderate' > 6 mm < 11 mm 570 / 56.5%
defect 'deep' ≥ 11 mm 128 / 12.7%
average bone loss 'shallow' 5.35 ± 0.76 mm
average bone loss 'moderate' 8.23 ± 1.05.mm
average bone loss 'deep' 12.09 ± 1.58 mm
bone loss (median) 8 mm

Table 2: Results of repeated measures linear mixed effects model for the response
“radiographic bone fill in mm”

Standard degrees of
Parameter Coefficient t value p value
error freedom
time frame 1 (one year; intercept) 0.210699 0.085798 1014.6 2.456 0.01522

time frame 2 versus 1 -0.062953 0.009589 1085.4 -6.565 <0.00001

time frame 3 versus 1 -0.090677 0.011527 1089.5 -7.866 <0.00001

with CM and/or EMD 0.078114 0.021009 836.9 3.718 0.00021

log (baseline BL) 0.572217 0.032333 1014.2 17.698 <0.00001

smoker 0.059424 0.032603 135 1.823 0.07057

number of walls -0.060534 0.019556 955.9 -3.095 0.00202

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 Table 3: Mean radiographic bone level (BL) + standard deviation (mm) over time calculated
for patients and teeth with different length of follow-up. Means for t2 (2 – 4 years) were 3.3 ±
0.7 years and for t3 (5 – 10 years) 6.4 ± 1.3 years. Analysis on the level of teeth, patient and
Accepted Article
deepest defect per patient.

Long-term Follow-up
bone level changes baseline t1 t2 t3
(mm +/- SD)

BL per teeth (n=1008)

7.84 + 2.33 4.01 + 1.44 n.a. n.a.

BL per patient (n=176) 8.14 + 1.98 4.16 + 1.31 n.a. n.a.

BL in deepest defect per

10.22 + 2.52 4.85 + 1.59 n.a. n.a.
patient (n=176)

BL per teeth (n =619 ) 7.86 + 2.28 3.89 + 1.42 3.71 + 1.5 n.a.

BL per patient (n = 123) 8.28 + 1.92 4.16 + 1.31 3.91 + 1.34 n.a.

BL in deepest defect per

10.17 + 2.48 4.85 + 1.58 4.49 + 1.62 n.a.
patient (n = 110)

BL per teeth (n=226) 7.62 + 2.21 4.09 + 1.47 3.63 + 1.39 3.72 + 1.58

BL per patient (n=53) 8.15 + 1.86 4.46 + 1.38 3.89 + 1.19 3.97 + 1.23

BL in deepest defect per

9.63 + 2.26 5.16 + 1.63 4.36 + 1.33 4.59 + 1.79
patient (n=41)

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Accepted Article
Table 4: Frequency distribution of residual BL and PPD for the subsample
that attended all visits from baseline to t3, BL: N = 226, PPD: N = 378

Frequency distribution of residual defects (BL) and probing depths (PPD)

BL (mm) baseline t1 t2 t3
2 0 33 58 55
3 0 48 65 67
4 6 65 53 51
5 33 47 22 27
6 51 20 19 12
7 27 6 4 6
8 34 6 4 5
9 30 0 1 2
10 16 1 0 0
11 19 0 0 0
12 6 0 0 1
13 2 0 0 0
14 1 0 0 0
16 1 0 0 0
PPD (mm) baseline t1 t2 t3

1 0 5 5 2
2 9 99 113 102
3 54 144 134 141
4 47 55 42 42
5 57 43 37 37
6 106 24 36 34
7 29 6 6 10
8 58 2 4 8
9 8 0 1 1
10 6 0 0 1
11 2 0 0 0
12 2 0 0 0

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Accepted Article

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Accepted Article

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