Regenerating a Periodontal Defect Using Augmentation With Octacalcium Phosphate–Coated 100% Cancellous Bone Mineral: Clinical Case Report

The stability of alveolar structures is dependent on the maintenance of the dynamic equilibrium between ongoing bone resorption and formation. This equilibrium may be compromised in the presence of periodontal disease where inflammatory cascades, such as those occurring in response to pathologic bacteria, shift the balance toward bone resorption accompanied by the destruction of connective tissue and gum recession.^1-6 Even after the condition is resolved or brought under control, periodontal tissue regeneration might be required to restore normal function.⁷

Bone grafting has commonly been used to regenerate ridges. However, the drawbacks of current methods—such as poor mechanical strength of certain biomaterials that may be inadequate in load-bearing regions,⁸ acid release exhibited by some synthetic polymers during their degradation, thus potentially causing an adverse impact on the bone,⁹ and potential immunological reactions from cadaver-derived bone—have driven the development and improvement of grafting materials and protocols in an effort to enhance outcomes.¹⁰ Many clinicians favor the use of xenograft materials because they offer slow resorption rates, biocompatibility, excellent osteoconductivity, uneventful healing, and stability at a competitive price.^11-15

Bone augmentation approaches that use deproteinized bovine bone mineral (DBBM) maintain volume effectively.¹⁶ However, the relatively slow absorption of this material correlates with a lower bone formation rate than that which is observed in natural healing.¹⁷ The inclusion of biodegradable materials such as bioactive ceramics into the grafting material may remedy this limitation.¹⁸ The nanoscale features present in the design of an optimal scaffold have recently emerged as a key factor in achieving desired characteristics in regenerated tissues.^4,19 For example, octacalcium phosphate (OCP) molecules, which are the biological apatite crystal precursors, convert into hydroxyapatite at physiological pH displaying high solubility and biodegradability. This occurs as osteoblastic cells align on the OCP’s surface and are accompanied by calcium ion consumption and inorganic phosphate ion release,²⁰ promoting osteoconductivity, osteoblast differentiation, and, consequently, new bone generation.^19,21 Clinicians may also combine bone graft materials with platelet-rich plasma (PRP) and platelet-rich fibrin (PRF) to provide growth factors, leukocytes, and circulating stem cells that otherwise may not be available to the bone graft.^22,23

A systematic review indicated that the use of PRP together with grafting biomaterials was associated with a lower percentage of residual bone substitute and a slightly higher rate of new bone formation than the use of graft materials alone.²⁴ However, a meta-analysis by another group of researchers found no statistically significant differences in rates of implant survival, new bone formation, or other aspects between non-PRF and PRF groups.²⁵ Nonetheless, a randomized clinical trial and prospective study where DBBM and PRF were combined—similar to the approach utilized in the present case report—found that the use of fibrin fostered suitable bone gain and was more effective at treatment of intrabony periodontal defects than the use of DBBM without PRF.^22,26

This case report describes the outcomes of a bone augmentation approach using OCP-coated DBBM consisting of purely cancellous bone mixed with autologous bone and adjuvant materials to salvage a tooth with a bone defect caused by periodontitis.

Case Presentation

A 65-year-old nonsmoking female patient with periodontitis presented with a bone defect on the mesial aspect of the maxillary left central incisor (tooth No. 9) (Figure 1 and Figure 2). The registered mobility index (Grace and Smales) was grade 2, ie, 1 mm to 2 mm buccolingual movement. During the grafting procedure, a soft-tissue flap was raised, revealing a deep periodontal defect (Figure 3 and Figure 4). Autogenous bone was harvested from the ramus and combined in a 1:2 ratio with DBBM (OCP-coated 100% cancellous bone) (Ti-oss®, Chiyewon Co. Ltd., ti-oss.com; distributed as creos™ xenoform, Nobel Biocare, nobelbiocare.com). The resulting material was mixed with highly concentrated platelets, obtained through an additional spin of PRP (referred to as platelet concentrates in a protocol adapted by the author), to which thrombin and calcium were added to generate a coagulated mass (Figure 5) that was used to fill the defect (Figure 6). Thrombin and calcium have been shown in vitro and in vivo to activate the platelets to release growth factors, thereby stimulating osteoblasts, enhancing angiogenesis, and promoting cell migration.^27,28

The site was then covered with PRF (Figure 7), with its gum-like consistency that prevented the bone graft from dispersing over the flap incision. This was especially important since no protective (collagen) membrane was applied. Subsequently, the soft tissue was sutured into place (Figure 8).

Composite veneering to conceal the midline diastema and improve esthetics was performed on the same day. Healing was uneventful. Long-term follow-up images at 5.6 years (Figure 9 and Figure 10) and 6.3 years (Figure 11) showed the long-lasting maintenance of the regenerated bone, tooth retention, and an adequate esthetic appearance with nearly optimal papilla.

Discussion

This case report describes a patient with periodontitis treated with OCP-coated, exclusively cancellous DBBM and adjuvant factors, resulting in a coagulated mass that was applied to the defect, covered with PRF, and sutured. This approach successfully stabilized and retained the periodontally involved tooth.

Ridge volume stability was maintained as the graft material was packed with moderate compression to allow for proper vascularization. This was further enhanced by the multiporous nature of the cancellous bone, characterized by a relatively large pore size (300 µm to 400 µm)²¹ that was conducive to cell migration, proliferation, and eventual differentiation, facilitating osseointegration.^4,29

Although a recent study found that OCP coating of the DBBM surface, which is gradually converted to hydroxyapatite, yielded levels of newly formed bone comparable to materials without OCP, it enabled greater biodegradability, leaving a lower amount of residual graft compared to control.¹⁴ However, previous reports did not find this difference to be statistically significant.^30-32

Within the limitations of the presented case, the described method utilizing 100% cancellous bone xenograft demonstrated overall success in bone regeneration for periodontal defect treatment. DBBM with adjuvant materials yielded uneventful healing and successful outcomes such as long-term stability of bone and soft tissues with satisfactory esthetics. A larger-scale study is needed to further substantiate the utility of this approach.

Conclusion

This case report highlights a promising regenerative strategy for periodontal bone defects, employing OCP-coated, 100% cancellous DBBM combined with autologous bone and platelet concentrates. The approach resulted in effective bone regeneration, stable ridge volume, and sustained clinical and esthetic outcomes over a long-term follow-up period. The use of PRF proved beneficial in maintaining graft stability and promoting healing. While the results are encouraging, further studies involving larger patient cohorts and controlled comparisons are warranted to validate the efficacy and reproducibility of this technique in broader clinical settings.

ACKNOWLEDGMENT

The author thanks Lisa Giles, PhD, of BioScience Writers for help with writing the first draft of this manuscript.

DISCLOSURE

The author serves as a key opinion leader for Chiyewon Co. Ltd. The clinical case data that support these findings are available from the author upon reasonable request. Manuscript preparation and article processing charges were supported by Nobel Biocare Services AG (grant number 2023-1771).

ABOUT THE AUTHOR

Myung Ho Lee, DDS

Private Practice, Wansan-gu, Jeonju-si, Jeollabuk-do, Republic of Korea

Figures and Images

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Figure 1

Fig 1. Pretreatment radiograph. Arrow indicates periodontal defect at tooth No. 9.

Figure 2

Fig 2. Pretreatment clinical image, with periodontal defect at tooth No. 9.

Figure 3

Fig 3. Intraoperative clinical image showing the periodontal defect.

Figure 4

Fig 4. Intraoperative clinical image with probe revealing the depth of the defect.

Figure 5

Fig 5. The grafting material was prepared by combining DBBM, platelet concentrates, and autogenous bone chips with calcium and thrombin to induce coagulation.

Figure 6

Fig 6. A soft-tissue flap was raised to apply the prepared bone grafting mix, filling the defect.

Figure 7

Fig 7. The graft was then covered by a PRF coagulate.

Figure 8

Fig 8. The soft-tissue flap was sutured into place.

Figure 9

Fig 9. Radiographic image at 5.6 years post-treatment affirming regenerated periodontal defect.