O impacto clínico e imunológico da matriz derivada de esmalte na cicatrização de cirurgias para recobrimento radicular / Clinical and imunological impact of enamel matriz derivative in root covering surgeries

O objetivo do presente estudo foi avaliar o impacto clínico e imunológico da matriz derivada de esmalte (EMD) na cicatrização periodontal, após a realização de cirurgias de recobrimento radicular. Dezesseis pacientes, com média de idade de 47,7 anos (DP=7,0), foram submetidos à cirurgia de recobrimento radicular com enxerto de tecido conjuntivo subepitelial associado ou não à matriz derivada de esmalte. O estudo seguiu o modelo de boca dividida e randomizado para os lados teste e controle. Os seguintes parâmetros clínicos foram analisados no dia da cirurgia e 6 meses após o procedimento cirúrgico: altura da recessão (AR), largura da faixa de gengiva queratinizada (LFG), largura da recessão (LR), profundidade de sondagem (PS), nível de inserção clínica (NIC) e espessura gengival (EG). Além da análise clínica, foram realizadas avaliações dos seguintes marcadores inflamatórios: IL-1ß, IL -1RA, IL-2, IL-4, IL-5, IL-6, IL-7, IL-8, IL-9, IL-10, IL12, IL-13, IL-15, IL-17, EOTAXIN, FGF, G-CSF, GM-CSF, IFN-, IP-10, MCP-1, MIP 1α, PDGF-bb, MIP 1ß, RANTES, TNF-α e VEGF, no fluido gengival no dia da cirurgia e com 7 e 14 dias de pós-operatório. Análise da dor pós-operatória e a análise estética também foram realizadas. Os resultados demonstraram que o lado tratado com EMD resultou em percentual de cobertura radicular (p=0,03) significantemente maior quando comparado com o lado controle. Setenta e cinco por cento dos sítios apresentaram cobertura radicular completa no lado teste e 43,8% no controle, em 6 meses. O EMD não trouxe resultados significantes para aumento de espessura gengival e ganho de faixa de tecido queratinizado. As análises imunológicas mostraram um aumento de VEGF (p=0,03) e PDGF (p=0,03) aos 14 dias de pós-operatório com o EMD e altas expressões de mediadores inflamatórios como IL-1ß (p=0,04; p=0,03), IL-6 (p=0,05; p=0,05), TNF-α (p=0,02; p=0,02), MIP-1α (p=0,02; p=0,05) com 7 dias de pós-operatório, em ambos os grupos, teste e controle, respectivamente. Não houve diferença entre os grupos na avaliação da dor pós-operatória e foi demonstrada uma diferença significante entre a avaliação da estética final do paciente daquela realizada por um profissional calibrado e experiente. Assim sendo, concluímos que o EMD parece ter impacto clínico e imunológico, nas cirurgias de recobrimento de raízes, com percentuais significantemente maiores de cobertura radicular e completa cobertura radicular assim como aumento significantemente maior na liberação de VEGF e PDGF-bb com 14 dias de pós-operatório, sugerindo ser um importante elemento para uma melhor cicatrização.

The aim of the present study was to evaluate the clinical and immunological impact of the enamel-derived matrix (EMD) on periodontal healing, after root-covering surgeries. Sixteen patients, mean age 47.7 years (SD = 7.0), underwent root-graft surgery with graft of subepithelial connective tissue associated or not with enamel-derived matrix. The study followed the split-mouth model and randomized to the sides test and control. The following clinical parameters were analyzed on the day of surgery and 6 months after the surgical procedure: height of the recession (AR), width of keratinized tissue (LFG), width of the recession (LR), probing depth (PS), clinical attachment level (NIC) and gingival thickness (EG). In addition to the clinical analysis, the following inflammatory markers were evaluated: IL-1ß, IL-1RA, IL-2, IL-4, IL-5, IL-6, IL-7, IL-8, IL-9, IL IL-13, IL-15, IL-17, EOTAXIN, FGF, GCSF, GMCSF, IFN-, IP-10, MCP-1, MIP-1α, PDGF-bb, MIP-1ß, RANTES, TNF-α and VEGF in the gingival crevicular fluid at baseline and at 7 and 14 postoperative days. Postoperative pain analysis and aesthetic analysis were performed. The results showed that the side treated with EMD resulted in a significantly higher percentage of root coverage (p = 0.03) when compared to the control side. Seventy-five percent of the sites had complete root coverage on the test side and 43.8% on the control side in 6 months. The EMD did not bring significant results to increase gingival thickness and gain of width keratinized tissue. Immunological analyzes showed an increase in VEGF (p = 0.03) and PDGF (p = 0.03) at 14 days postoperatively with EMD and high expression of inflammatory mediators such as IL-1ß (p = 0.04) (P = 0.05), MIP-1α (p = 0.05), TNF-α (p = 0.02, p = 0.02) 02, p = 0.05) with 7 postoperative days, in both groups, test and control, respectively. There was no difference between the groups in the evaluation of postoperative pain and a significant difference between the evaluation of the final aesthetic of the patient and the one performed by a calibrated and experienced professional was demonstrated. Thus, we concluded that EMD appears to have a clinical and immunological impact in root coverage surgeries, with significantly greater percentage of root coverage and complete root coverage, as well as a significantly higher increase in the release of VEGF and PDGF-bb with 14 days of postoperative, suggesting to be an important element for a better wound healing.

Uso da matriz derivada do esmalte (mde) associada ao vidro bioativo no tratamento de defeitos infra-ósseos: uma revisão de literatura / Use of enamel matrix derivate (EMD) associated with bioactive glass in the treatment of intraosseous defects: A Literature Review

A regeneração periodontal tem como objetivo recuperar as estruturas perdidas (osso alveolar, cemento e ligamento periodontal) como sequelas da doença periodontal. O conhecimento da Matriz Derivada do Esmalte (MDE) tem na literatura uma ampla aplicação, porém sua relação direta associada aos vidros bioativos é pouco caracterizada em todas suas vias, nesse contexto este estudo teve como proposta baseada numa revisão literária por meio de bases de dados (Pubmed, Scielo, lilacs), discutir aspectos importantes sobre a avaliação da efetividade clínica do vidro bioativo em combinação com a MDE (Emdogain) principalmente em defeitos infra-ósseos. O Emdogain (EMD) sozinho ou em associação a outros biomaterais de enxertia parece promover ganhos na regeneração tecidual de tecidos perdidos pela periodontite, porém sua associação tem-se poucos resultados significativos que justifiquem sua ampla utilização, sua indicação deve estar baseada em um bom diagnóstico periodontal e da morfologia do defeito infraósseo. Assim, tornam-se necessários mais estudos para elucidar interações e mecanismos celulares envolvidos no complexo de ação para justificar o seu uso.(AU)

Periodontal regeneration aims to recover the lost structures (alveolar bone, cementum and periodontal ligament) as sequelae of periodontal disease. The knowledge derived from the enamel matrix (EMD) is in the literature a wide application, but its direct relationship associated with bioactive glass is poorly characterized in all its way in this context this study was proposed based on a literature review through databases (Pubmed, Scielo, lilacs), discuss important aspects of the evaluation of the clinical effectiveness of bioactive glass in combination with EMD (Emdogain) mainly intraosseous defects.Emdogain (EMD) alone or in association with other biomaterials of grafting appears to promote gains in the tissue regeneration of lost tissues by periodontitis, but its association has few significant results that justify its wide use, its indication must be based on a good periodontal diagnosis and infraosseous defect morphology. Thus, further studies are needed to elucidate interactions and cellular mechanisms involved in the action complex to justify its use.(AU)

Retalho deslocado coronalmente com a utilização de enxerto conjuntivo subepitelial e Emdogain para recobrimento radicular ­ controle clínico de cinco anos / Coronally repositioned flap with subepithelial connective tissue graft and Emdogain for root coverage ­ a 5 year follow-up case report

Uma situação desafiadora na Odontologia é a recessão gengival. Seu tratamento deve ser capaz de promover um completo recobrimento do defeito da recessão com mínima profundidade de sondagem pós-tratamento, além de promover resultados de cor e textura na área recoberta compatível com a dos tecidos moles adjacentes. Algumas situações clínicas prévias devem ser observadas quando do exame do paciente, dentre elas: a etiologia da lesão, o grau de classificação e a existência de lesões cariosas na raiz exposta. Uma abordagem previsível para o recobrimento radicular é o retalho deslocado coronalmente associado ao enxerto de tecido conjuntivo subepitelial. As proteínas derivadas da matriz do esmalte vêm sendo utilizadas associadas a técnicas de recobrimento com o intuito de aumentar o potencial regenerativo da região. Neste relato, com controle clínico de cinco anos, foi realizada a recuperação do tecido gengival perdido na região do dente 31, com o uso da técnica do retalho deslocado coronalmente associado ao enxerto de tecido conjuntivo subepitelial e ao Emdogain. Esta associação resultou em um importante ganho de inserção, além da melhora estética na região para o paciente.

A challenging situation in dentistry is gingival recession. Its treatment should be able to promote a complete coverage of the recession defect with minimum post-treatment probing depth, in addition to promoting color and texture results in the covered area compatible with the adjacent soft tissue. Some previous medical conditions must be observed when examining the patient, among them the etiology, the degree of classifi cation and the existence of caries on the exposed root. A predictable approach to root coverage is the coronally repositioned flap associated with subepithelial connective tissue grafting. The enamel derived matrix has been associated with coverage techniques in order to increase the regenerative potential. In this 5 year case report, the lost gingival tissue was recovered at the region of tooth 31 using a coronally advanced fl ap associated to STG and Emdogain. There were esthetic improvements and better attachment levels observed in the clinical results.

Avaliação comparativa entre as técnicas de recobrimento radicular com enxerto de conjuntivo associada ou não à matriz derivada de esmalte (Emdogain) / Comparative evaluation of techniques for root coverage with connective graft associated or not with enamel matrix derivative (Emdogain)

As recessões gengivais são motivos frequentes de visitas aos consultórios odontológicos devido à sua presença causar prejuízos estéticos ao sorriso, além de sensibilidade dolorosa. Existem muitas técnicas descritas na literatura para o recobrimento das raízes expostas, minimizando as consequências das recessões. O objetivo deste trabalho é analisar a técnica de enxerto de tecido conjuntivo e a utilização do Emdogain® para o recobrimento de recessões gengivais e comparar os benefícios de cada uma. Para isso realizou-se uma revisão de literatura a partir de um levantamento bibliográfico utilizando a base de dados da United States National Library of Medicine (PubMed) durante o período entre 2008 e 2013. Foram encontrados 74 estudos no total. Quarenta e sete estudos foram selecionados e coletados. Após aplicação dos critérios de inclusão, vinte e três artigos foram selecionados para a confecção da revisão de literatura e dez passaram por uma análise comparativa a fim de possibilitar a coleta de dados e particularidades de cada estudo. Após a análise comparativa, as duas técnicas demostraram ser efetivas para o tratamento das recessões gengivais e apresentaram taxas semelhantes de cobertura radicular. O uso do enxerto de tecido conjuntivo (ETC) tem a desvantagem de possuir um sítio doador, o que pode causar maior desconforto pós-operatório, por outro lado, as proteínas derivadas da matriz do esmalte (PDME) têm a desvantagem de possuir um alto custo.

Gingival recessions are common reasons for visits to dental offices because of their presence and cause cosmetic damage to smile and soreness. There are many techniques described in the literature for the covering of exposed roots, thus minimizing the effects of recessions. The objective of this work is to analyze the technique of connective tissue graft and use of Emdogain® for coverage of gingival recession and compare the benefits of each. For this we carried out a literature review from a literature survey using the database of the United States National Library of Medicine (PubMed) during the period between 2008 and 2013. Seventy-four studies were found in total. Forty-seven studies were selected and collected. After applying the inclusion criteria, twenty three articles were selected for the preparation of the literature review and ten went through a comparative analysis to enable data collection and particularities of each study. After a comparative analysis, both techniques have shown to be effective for the treatment of gingival recessions and had similar rates of root coverage. The use of the ETC has the disadvantage of having a donor site, which can cause greater discomfort after surgery, on the other hand, PDME has the disadvantage of having a high cost.

Regeneración tisular guiada en defecto óseo de 3 paredes: enfermedad periodontal y oclusión / Guided tissue regeneration and in a three-walled osseous defect: periodontal disease and occlusion

Relacionar la importancia del éxito en regeneración tisular guiada y el correcto diagnóstico del problema, en este caso enfermedad periodontaly un contacto prematuro en ORC producto de una obturación de amalgama incorrecta. Caso clínico: tratamiento de un defecto infraóseo de3 paredes mediante la utilización de hueso de origen bovino particulado junto con proteínas derivadas de la matriz del esmalte. Tanto los parámetros clínicoscomo los radiográficos fueron evaluados al inicio, en el postquirúrgico inmediato y a los 12 meses. Conclusión: se observó un alto grado de regeneración pasados los 12 meses del tratamiento. Parecería no ser siempre necesaria la utilización de membrana colágena. Las proteínas derivadas de la matrizdel esmalte serían un sustituto de la membrana en algunos casos. Resulta fundamental el chequeo de la situación oclusal en piezas periodontalmente comprometidas...

The effect of Emdogain gel on periodontal regeneration in autogenous transplanted dog's teeth.

Aim: The aim of this study was to assess the enamel matrix derivative (EMD) as biomaterial used in autogenous tooth transplantation. Material and Methods: The study consisted of 3 beagle dogs, 5 months old, in which six incisors and six premolars were transplanted to mechanically prepared recipient alveolar sockets. One group of teeth was transplanted to a recipient bed, with EMD in the root surface. The second groups of teeth were transplanted using saline solution in the root surface. Every week, clinical examinations were done. Nine weeks later, the animals were killed and the specimens decalcified and prepared for histological and imunohistochemical analysis. Periodontal healing was evaluated by undertaking histomorphometric investigation and analyzed using the Mann- Whitney test (P = 0.05). Results: In both groups, all the transplanted teeth survived. Between the experimental groups, there was statistically significant difference in the complete healing (P = 0.004). There was statistically significant difference between the treatment group in the occurrence of inflammatory root resorption (P = 0.015) and the occurrence of replacement root resorption (P = 0.041). Conclusions: Emdogain gel used on the surface of transplanted teeth improves the occurrence of complete healing and reduces root resorption.

Cellular viability and genetic expression of human gingival fibroblasts to zirconia with enamel matrix derivative (Emdogain(R))

PURPOSE: The objective of this study was to investigate the biologic effects of enamel matrix derivative (EMD) with different concentrations on cell viability and the genetic expression of human gingival fibroblasts (HGF) to zirconia surfaces. MATERIALS AND METHODS: Immortalized human gingival fibroblasts (HGF) were cultured (1) without EMD, (2) with EMD 25 microg/mL, and (3) with EMD 100 microg/mL on zirconia discs. MTT assay was performed to evaluate the cell proliferation activity and SEM was carried out to examine the cellular morphology and attachment. The mRNA expression of collagen type I, osteopontin, fibronectin, and TGF-beta1 was evaluated with the real-time polymerase chain reaction (RT-PCR). RESULTS: From MTT assay, HGF showed more proliferation in EMD 25 microg/mL group than control and EMD 100 microg/mL group (P<.05). HGFs showed more flattened cellular morphology on the experimental groups than on the control group after 4h culture and more cellular attachments were observed on EMD 25 microg/mL group and EMD 100 microg/mL group after 24h culture. After 48h of culture, cellular attachment was similar in all groups. The mRNA expression of type I collagen increased in a concentration dependent manner. The genetic expression of osteopontin, fibronectin, and TGF-beta1 was increased at EMD 100 microg/mL. However, the mRNA expression of proteins associated with cellular attachment was decreased at EMD 25 microg/mL. CONCLUSION: Through this short term culture of HGF on zirconium discs, we conclude that EMD affects the proliferation, attachment, and cell morphology of HGF cells. Also, EMD stimulates production of extracellular matrix collagen, osteopontin, and TGF-beta1 in high concentration levels. CLINICAL RELEVANCE: With the use of EMD, protective barrier between attached gingiva and transmucosal zirconia abutment may be enhanced leading to final esthetic results with implants.

Enamel matrix derivative for replanted teeth in animal models: a systematic review and meta-analysis

OBJECTIVES: To investigate the effect of enamel matrix derivative (EMD) on periodontal healing of replanted teeth in animal models. MATERIALS AND METHODS: The authors searched MEDLINE, PubMed, EMBASE, Cochrane Library, Web of Knowledge and Scopus for articles published up to Oct 2012. Animal studies in which EMD was applied in transplanted or replanted teeth with adequate controls and histological data were considered. Normal periodontal healing or root resorption determined by histology after EMD was applied in replanted teeth with adequate controls was used as outcome measures. The following search strategy was used: ('Emdogain' OR 'enamel matrix proteins' OR 'enamel matrix derivative') AND ('avulsion' OR 'transplantion' OR 'autotransplantation' OR 'replantation'). RESULTS: Six animal studies were included in the final review. There was great heterogeneity in study design among included studies. Two studies with similar study designs were identified and analyzed by a meta-analysis. The pooled estimates showed a significantly higher normal healing and surface resorption and significantly less inflammatory and replacement resorption in EMD-treated groups compared with non-EMD-treated groups. CONCLUSIONS: With the limitations of this systematic review, the use of EMD led to greater normal periodontal healing and surface root resorption and less inflammatory and replacement root resorption in the presence of periodontal ligaments. However, no definite conclusion could be drawn with regard to the effect of EMD on periodontal healing and root resorption when no periodontal ligaments exist.

Different gene expressions in human periodontal cells after being treated with Emdogain / 实用口腔医学杂志

Objective:To study the different gene expressions in human periodontal cells after being treated with Emdogain(EMD). Methods: The fourth passage periodontal cells were cultured. Cells in experimental group were cultured with 100 μg/ml EMD in non-serum DMEM for 3 days. Cells in control group were cultured in non-serum DMEM for 3 days. The gene expressions in human periodontal cells were screened with gene chip technique. Results: There were 112 differently expressed genes, 11 down-regulated genes and 101 up-regulated genes. Conclusion: After treated with Emdogain, expression of genes related to cell growth, cell proliferation, biosynthesis of extracellular matrix, angiogenesis and osteogenesis is up-regulated dramatically. Genes related to lipid metabolization and keratinocyte growth is down-regulated in human periodontal cells.

Effects of enamel matrix protein derivatives on the periodontal ligament like fibroblast and osteoblast like cells / 대한치주과학회지

Recent study on the enamel matrix derivatives explained on the effects of new bone and new attachment formation in infrabony pocket of periodontal defects. The purpose of this study was to investigate on the biological effects of enamel matrix derivatives to attachment, proliferation and activation of periodontal ligament and osteoblast cells. After treatment of osteoblast and PDL cells with various Emdogain concentration level(0.03microgram/ml, 3microgram/ml, 300 microgram/ml), activation of osteogenetic factor, calcified nodule formation and measuring alkaline phosphatase activity(ALP) were performed. 1. Both osteoblast and PDL cell showed increasing initial cell attachment with 300microgram/ml Emdogain concentration. 2. At the level of 300microgram/ml, accelerated proliferation of oseoblast and PDL cell was appeared. 3. As Emdogain's concentration increased, increased ALP activation of osteoblast was shown. In case of PDL cell, Emdogain increased ALP activation prominently at the level of 300microgram/ml. 4. No statistically significant activating change were founded at all of the concentrations of Emdogain on the activating of transcript factor Runx2 for differentiating osteoblast. 5. At the level of 300microgram/ml, calcified nodule formation was increased prominently to compare with other concentration. These results indicated that Emdogain should activate initial attachment, proliferation and activation, but not on Runx2 activation and can be used for useful tool of the treatment of periodontal tissue regeneration.