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Perhaps the most important attribute of living or- cedes physiological competence. In regeneration, which
ganisms is their capacity for self-repair. This implies is an example of postembryonic development, the dis-
an ability continously to monitor normal tissue func- tinction between morphology and physiology is not so
tion and to respond appropriately to any deviations well defined. To be sure, nothing can function until its
from the normal state. In its most ubiquitous form, material substrate is in place, yet nature has contrived
self-repair is accomplished through the physiological that no structure shall not regenerate unless it will
adaptations of the body in an effort to maintain a become functional. Not only is regeneration a morpho-
steady state. These adaptations, which occur at virtu- logical outgrowth from the adult, it is also a functional
ally all levels of organization, are achieved by classic restoration. Thus in the very initiation of regeneration,
negative feedback loops. Imbalance at the molecular there has evolved a dependence on physiological inf lu-
level is corrected by appropriate equilibrium shifts in ences that integrates the activities of the future regen-
chemical reactions. At the cell and tissue levels, ho- erate with those of the rest of the body. This utilitarian
meostasis is maintained through a careful balance of imperative ensures that useless structures are gener-
biosynthetic and degradative processes. At higher lev- ated a t the expense of more important processes. This
els of organization, some organism are capable of re- report addresses current concepts of the cellular and
generating entire tissue and organ structures includ- molecular aspects of periodontal regeneration and dis-
ing appendages. In mammals, any injury to body parts cusses their potential clinical application.
will normally heal by repair or regeneration that is
dependent on the nature of the wounded tissue. PERIODONTAL CONSIDERATIONS TO THE
Whereas some tissues such as epithelia retain substan- REGENERATING PROCESS
tial regenerative potential throughout life, others such
as nervous or connective tissue may preferentially heal In periodontal diseases, inflammation of the support-
by a repair process, especially under the influence of ing structures of the tooth, or periodontitis, causes dis-
chronic infection. tinct changes in the periodontium, which subsequently
Although repair and regeneration are usually impact on its regenerative potential. Collagen tissues
thought of in morphological terms, there is an impor- are lost from the root surface, which becomes exposed
tant functional consideration. Thus the repaired tis- to inflammatory processes, soft and hard bacterial de-
sues must carry out the same physiological activities posits, and the oral environment. The alveolar bone
performed by the original structures. Otherwise, re- and periodontal ligament are reduced in height and
growth would be useless and an expensive drain on the
resources of the organisms. Clearly, there is an essen-
tial functional dimension to repair and regeneration, a
Address reprint requests to Salomon Amar, D.D.S., Boston Univer-
dimension inseparable from the morphological one. It sity, Center for Advanced Biomedical Research, Department of Oral
might be asked which comes first, structure or func- Biology and Periodontology, W201-C, 700 Albany Street, Boston, MA
tion? In embryogenesis, structural development pre- 02118.
0 1996 WILEY-LISS, INC.
362 S. AMAR
Initial Clot Formation ation, progenitor cell manipulation, cell exclusion (gin-
gival and epithelial), wound stabilization, and growth
1
Necrosis/ResorptiveActivity
factor enrichment.
Attempts to manipulate these biologic parameters
have led to minimal success partly because of the lack
of knowledge of basic mechanisms of molecular peri-
Granulation Tissue odontal wound healing, along with complications of the
wound healing inherent to the periodontal environ-
ment. Furthermore, reparative and regenerative pro-
cesses in the periodontium occur in anatomical sites
and under conditions that are considerably more com-
R ulation of Root Syrface plicated than for incisional wounds. Complications in-
&POPfenotypic Expression herent to periodontal wound healing include: (1) oral
microbial plaque: healing of the wound occurs in pres-
ence of a microflora deleterious to the process, (2) phys-
ical environment: variations in pH and/or temperature
often occurring in the oral environment can impair the
REPA1R REGENERATION wound healing process, (3)root surface: the contribu-
Fig. 1. Temporal pattern of healing following periodontal insult.
tion of this avascular surface to the wound healing pro-
cess is minimal, (4) multiple interacting cells: epithe-
lial and various connective tissue cells must work in
concert to reestablish the periodontal attachment
volume and are replaced by inflamed connective tissue apparatus, (5) cell-matrix interactions: the extensive
and the downgrowth of the gingival epithelium. matrix destruction occurring in periodontitis affects
It is important to consider the treatment of the in- tremendously the wound healing process, and (6) func-
flammatory response in the periodontium and the tional considerations: deleterious occlusal forces can af-
treatment of the anatomical defects produced by peri- fect wound stabilization during the healing process.
odontitis as two distinct entities. Periodontitis is be- Given all the aformentioned considerations, it is not
lieved to be a bacterial plaque-induced inflammatory surprising that various flap procedures and root sur-
process in which the supporting alveolar bone, peri- face conditioning protocols have provided only limited
odontal ligament, and the surrounding connective tis- evidence of periodontal regeneration (Listgarten and
sue are destroyed. Treatment of periodontitis involves Rosenberg, 1979; Caton et al., 1980; Stahl et al., 1982;
mechanical and chemotherapeutic procedures aimed at Froum et al., 1983; Moore et al., 1987). However, aside
eliminating pathologic microorganisms that invoke the from certain osseous grafting techniques (Hiatt et al.,
inflammatory response. This treatment, however, en- 1978; Bowers et al., 1991; Mellonig, 1991), studies on
genders a defect characterized clinically by bone and guided tissue regeneration outcomes (Fig. 3) have
periodontal ligament loss, gingival pockets, and reces- proven the most convincing histologic evidence of sig-
sion of the gingival margin. Periodontal surgery is di- nificant periodontal regeneration. Nyman and co-
rected primarily at resolving these defects, either by workers (Nyman et al., 1982a,b)were the first to report
repair or preferably through regeneration (Fig. 1). the formation of a new attachment by means of using
Periodontal repair represents the healing process af- Millipore filters to prevent gingival epithelial and con-
ter periodontal surgery that does not lead to the re- nective tissue cells to invade and perturb the periodon-
placement of the lost periodontal tissues, whereas peri- tal wound area. Subsequently, several studies (Gottlow
odontal regeneration represents a healing process after et al., 1984, 1986; Aukhil et al., 1986; Caffesse et al.,
periodontal surgery which results in the formation of 1990; Caton et al., 1992) have reported histological ev-
new cementum, new bone, and new periodontal liga- idence of the regenerative capacity of the periodontal
ment on a tooth root surface that has been previously ligament cells. Whereas the cellular and molecular cas-
exposed to the periodontal disease (Fig. 2) (Kalkwarf, cade of events associated with periodontal regeneration
1974). is not completely understood, recent data hold great
Conventional therapy for periodontal defects consists promise for the modulation and/or control of the peri-
in scaling and root planing of the diseased root surface, odontal regeneration process to achieve a predictable
gingival curettage, and various other surgical proce- outcome.
dures, with and without implants of bone and/or bone
substitutes. The rationale for many of these therapeu-
tic procedures is regeneration of the periodontium. CELLULAR ASPECTS
However, histological data supported by several labo- The process of periodontal regeneration involves a
ratories (Yukna, 1976; Listgarten and Rosenberg, number of cell phenotypes, including cementoblasts,
1979; Moskow et al., 1979; Caton and Nyman, 1981; endothelial cells, epithelial cells (sulcular and junc-
Steiner et al., 1981) indicates that repair rather than tional), fibroblasts, and osteoblasts, as well as nerve
regeneration results from conventional periodontal cells. True periodontal regeneration entails the re-es-
therapy. This knowledge has redefined the rationale tablishment of new cementum with inserting collagen
for conventional periodontal therapy and has focused fibers and supporting alveolar bone (Nyman et al.,
attention on the more basic aspects of wound healing in 1982a,b). However, the heterogeneity of the cell popu-
the hope of identifying important variables for peri- lation of the periodontal ligament, together with the
odontal regeneration, which include: root surface alter- lack of definitive cell differentiation markers, has
ADVANCES IN PERIODONTAL REGENERATION 363
New cementum, Long Junctional Connective & Connective & Bony ankylosis
bone & PDL fibers Epithelium partly attached non-attached Attachment
Bone-like tissue Bone-like tissue
Attachment Attachment
Matrix s t i m u l a t e 7
attract Stem Cells
ROOT
SURFACE
ROOT
SURFAC
Migrating Periodontal Stem Cell undergoing Mitosis 8
Differentiation into Cementoblasf Fibroblast 8 Osteoblast
Comrnited Cernentoblasi
Fig. 4. Possible response of periodontal stem cells during periodon- Progenitor Cell 4
tal wound healing. Commited Osteoblast
Progenitor Cell
PhySlCOChemlCal
Matrix Lysis
structurestrength)
COLLAGEN THROMBOSPONDIN
FIBRIN
2 /
EXTRACELLULAR
/MATRIX FUNCTIONS
Fig. 6. Interactions between extracellular m a t r i x and cells during e a r l y periodontal wound healing.
healing periodontal tissues, which grew beneath the the bone matrix and are characterized by their ability
expanded polytetrafluoroethlylene (ePTFE) mem- to induce cartilage and bone formation in vivo. To date
brane, further suggests that under these conditions the seven molecules, which have been named BMP-1
healing tissue expresses specific macromolecules that through BMP-7, have been identified and their corre-
may be important in periodontal regeneration. These sponding molecular clones obtained using fragmentary
multifunctional matrix glycoproteins found in the fi- amino acid sequence information from bone-inductive
brin clot have been shown not only to regulate cellular extracts derived from bovine bone (Celeste et al., 1990;
activity of migration, division, and differentiation but Ozkaynak et al., 1990; Wozney et al., 1990). These
also to influence the lysis, synthesis, and maintenance amino acid sequences allowed the design of multiple
of the ECM. Taken together, these results suggest that oligonucleotide probes, which were initially used to ob-
matrix glycoproteins may have a significant influence tain bovine genomic or complementary DNA (cDNA)
from the earliest phase of healing as adhesive mole- clones for each of the BMPs (Wozney et al., 1988).
cules for cell attachment and chemoattraction of cells These bovine clones were used to isolate human cDNA
into the wound area to the late phase of differentiation clones that contained the entire coding sequences for
and maturation of the wounded tissue. each of the individual BMPs. The human cDNAs for
BMP-1, BMP-2, BMP-4, BMP-5, and BMP-7 were each
Growth factors and cytokines derived from libraries constructed from the human os-
The ECM also serves as a reservoir of growth factors teoblastlike osteosarcoma cell line U-2 OS, the BMP-3
(FGF, Rifkin and Moscatelli, 1989;TGF-P, McCaffrey et cDNAs were derived from a cDNA library of the H128
al., 1989),cell-ceI1adhesion molecule (NCAM, Sanes et small cell lung carcinoma cell line, and clones for
al., 1986), and proteases (Silverstein et al., 1986) that BMP-6 were initially derived from U-2 0s cDNA li-
can be released during the temporo-spatial differenti- braries and subsequently from human placenta and
ation and maturation of the wound. Recent research brain cDNA libraries. Other reports have indicated the
have revealed an increasing number of bioactive mol- cloning of BMP-7, also called osteogenic protein-1 or
ecules including various growth factors-PDGF, (Mat- OP-1, from hippocampus and placenta libraries (Oz-
suda et al., 1992; Oates et al., 1993), TGF-P (Ignotz and kaynak et al., 1990).
Massague, 1986; Roberts et al., 1986; Overall et al., From the primary amino acid sequences of the hu-
19891,IGF-1 (Blom, 1992), BMP (Wozney, 1989; Wang, man BMPs derived from these molecular clones, six out
1993), FGF (Sanes et al., 1986)-and cytokines (IL-1, of the seven BMPs were found to be related to each
LIF) that have profound effects on various cell pheno- other and to be member of the TGF-p superfamily. An
type (Table 2). However, the regulatory mechanisms alignment of these amino acid sequences indicated that
that govern their functional interactions have yet to be significant amino acid identity exists among all the
fully elucidated. Transforming growth factor-p (TGF- BMPs in the carboxy-terminal region of the proteins.
P), which together with its homologues form a family of This region contains seven cysteine residues, whose
cytokines within the TGF-P superfamily of related mac- presence and relative positions are conserved among
romolecules exhibits numerous pleiotropic effects on all reported members of the TGF-P superfamily. Simi-
connective tissue cells. Tissue-specificeffects have been lar to the other members of the TGF-P family, the
demonstrated for TGF-P, particularly in regulating cell BMPs are synthesized within the cell in a precursor
activity and function in the process of bone metabolism form. Analysis of the primary amino acid sequences of
and wound healing, (Noda and Rodan, 1986; Centrella the six related BMPs allows them to be grouped into
et al., 1987;Kasperk et al., 1990; Wergedal et al., 1990). three separate sets. One set consists of BMP-2 and
Bone morphogenetic proteins (BMPs) are structur- BMP-4, which are 92% identical in the seven-cysteine
ally related to the TGFPs and form an other group of region; in fact, BMP-4 was originally isolated by cross-
cytokines within the TGF-f3 superfamily. BMP is a hybridization to a BMP-2 probe. BMP-5, BMP-6, and
term first used by Marshal Urist (1965) and now refers BMP-7 are also closely related to one another, possess-
to a family of growth factors that can be isolated from ing an average of 89% amino acid identity in their
ADVANCES IN PERIODONTAL REGENERATION 367
TABLE 2. Pleotropic cytokines
Cytokine Origin Function References
BMP-2 Osteoblast, bone, Induction of cartilage and bone; Wozney et al. (1990); Thies et al.
Deriodontal healinn
+
. differentiation of osteoblasts from (1992)
iissue progenitor cells
IGF Plasma, bone, Wound healing, increased mitogenesis, McCarthy et al. (1989); Lynch et
macrophage, osteoblast chemotaxis & synthesis of noncollagenous al. (1991a,b)
protein in fibroblasts; bone formation
FGF Bone, osteoblast, Angiogenic; mitogenic & chemotactic for Canalis et al. (1991); Basilico et
macrophage PDL fibroblasts; proliferation of al. (1992); Frenkel et al.
osteoblastic cells (1992)
PDGF Platelet; endothelial, Mitogenic toward fibroblastic and Terranova and Wikesio (1987);
mesenchymal cells, bone osteoblastic cells; stimulate bone matrix Centrella et al., 1989; Piche
& macrophage formation; stimulate secretion of and Graves (1989); Graves &
fibronectin & collagenase Cochran (1990); Zhang et al.
(1991)
TGF-P Bone matrix, platelet, Regulate osteoblastic and fibroblastic cell Ignotz & Massague (1986);
macrophage, osteoblast replication, differentiation & matrix Roberts et al., 1986;
synthesis; chemotactic & weekly mitogenic Postlethwaite et al. (1987);
for osteoblasts & fibroblasts; stimulate Canalis et al. (1988);
angiogenesis Kingsworth & Slavin, 1991
LIF Bone marrow stromal cells Stimulate growth & proliferation of Rodan et al., 1990; Verfaillie
multipotential progenitor cells; inhibit and McGlave (1991); Escary et
differentiation & maintain stem cells; al. (1993)
stimulate alkaline phosphatase in
presence of retinoic acid in osteoblastic
precursors
BSP Cells involved in Mediate initial stages of connective tissue Chen et al. (1992); Young et al.
formation of mineralized mineralization; may be marker of bone (1992)
matrix, bone, dentin, differentiation
cementum
corresponding regions, and define a second BMP sub- sue to form hard tissues. The recent demonstration of
set. BMP-3 is the sole member of the third subset iden- BSP, osteonectin and BMP-2 (Chung et al., 1994; Amar
tified to date. The BMP-2/BMP-4 and BMP-S/BMP-6/ et al., 1995) in human healing periodontal soft tissue
BMP-7 subsets are more closely related to one another grown beneath ePTFE membranes suggests that this
than they are to BMP-3. wound tissue contains cells and matrix macromole-
BMPs, like all the members of the TGF-P family, act cules required for hard tissue formation. Along the
through specific receptors. A single report described same line of ideas, we have examined the expression of
the presence of high-affinity binding sites for BMP-4 on bone macromolecules in primary cultures of cells which
MC3T3-El and NIH3T3 cells. By cross-linking exper- outgrew from human tissue explants retrieved after
iments, binding proteins of 200 and 70 kDa are present barrier-membrane (ePTFE) placement onto periodon-
on MC3T3-El cells, whereas proteins of 200 and 90 tal defects following the concept of guided tissue regen-
kDa are present an NIH3T3 cells (Paralkar et al., eration. Control cells were obtained from the out-
1991). It is perhaps surprising that there are receptors growth of gingival connective tissues harvested after
of different sizes for the same protein on two cell types flap replacement procedure. Cells (control and experi-
of the same species. No competition by TGF-P was mental) were plated on coverslips and fixed according
found for the BMP-4 binding proteins, nor was compe- to Amar et al. (1991). Cells were immunostained at
tition by BMP-4 for the TGF-p receptors observed con- different timepoints of culture against BMP-2 (gra-
sistent with most of the activity data on cells in vitro. ciously provided by Dr. Wozney, Genetics Institute),
Several BMPs, including BMP-2 and BMP-3 (osteo- osteonectin (OTN), and bone sialoprotein (BSP) (gra-
genin), have been shown to induce ectopic bone forma- ciously provided by Dr. Larry Fisher NIH-NIDR), and
tion in vivo (Wang et al., 1990; Ripamonti et al., 1993a) BMP-7 (graciously provided by Dr. Bruce Rutherford,
by initiating local differentiation of mesenchymal cells University of Michigan). Samples were incubated for 2
into bone-forming cells. However, most studies (Mar- hours a t room temperature. An affinity purified, per-
den et al., 1993; Ripamonti et al., 1993a,b) seem to oxidase-labeled goat antimouse (BMP-2) and antirab-
suggest that BMPs requires the combination with a bit (OTN, BSP) IgG antibody was used as the secondary
carrier matrix for effective bone induction. BMP-7 also antibody (Elite Vectastain ABC kit) following the in-
has been demonstrated to induce terminal differentia- structions of the manufacturer (Vector Laboratories,
tion of chondroblasts and osteoblasts within the con- Burlingame, CA). Peroxidase activity was developed
text of endochondral bone ossification (Sampath et al., using 0.05%3.3' diamino-benzidine (Sigma Chemical,
1992; Asahina et al., 1993; Knutsen et al., 1993). St. Louis, MO) in Tris-HC1 buffer (pH 7.6) containing
The presence of these specific macromolecules in the 0.001% HZOp.
ECM has been used as markers to determine the in- As shown in Figure 7, cells harvested from tissues
trinsic potential of the periodontal healing wound tis- growing under the membrane barrier (ePTFE) and cul-
368 S. AMAR
Fig. 7. Cells harvested from tissues growing under the membrane barrier and culturedfor 5 days were
immunostained against BMP-2 at a dilution of 1/50 in PBS (a),Bone Sialoprotein(BSP) at a dilution of
1/40 in PBS (c),and Osteonectin(OTN)at a dilution of 1/40 in PBS (d).High levels of BMP-2(a)and BSP
(c) are expressed in the cytoplasm,whereas moderate levels of OTN are observed. (b)Gingival fibroblast
cells immunostained against BMP-2 (similar dilution as above); note the lack of staining. Similar ob-
servations were made when gingival fibroblasts were stained against BSP (not shown). (inverted micro-
scope x35)
tured for 5 days expressed high levels of BMP-2, OTN, mechanisms orchestrating cell-matrix interactions in
and BSP, whereas gingival fibroblast cells expressed the periodontal wound environment are needed to shed
only low levels of OTN (data not shown). Gingival fi- more light into these complex events.
broblast cells did not express BMP-2 (Fig. 7) or BSP
Collagen
(data not shown). Cells harvested from periodontal soft
tissue grown under the membrane barrier (ePTFE) and Type I collagen is the major structural component of
left in culture for 21 days in DMEM medium enriched the periodontal ligament fibres and the matrix of bone
in 10%serum aggregated to form nodules corroborat- and cementum. In fact, 70%of the total protein in the
ing previous observations using periodontal fibroblasts periodontal membrane is collagenous in nature and
(Arceo et al., 1991).These cell cultures heavily stained 85% (Narayanan and Page, 1983) is type I collagen.
for BMP-2 and BMP-7. None of the gingival cell cul- Type I collagen (Grinnell and Bennett, 1978;Postleth-
tures developed any nodules nor expressed BMP-2 or waite et al., 1978; Nishikawa et al., 1987; Hyder et al.,
BMP-7 to the limit of our detection method (Fig. 8). 1992) is known to harbor chemotactic and mitogenic
These preliminary data strongly suggest that cells activity for fibroblasts in vitro as well as being toler-
growing from tissue explants retrieved after barrier- ated by host tissue following in vivo implantation in
membrane placement express in culture tissue-specific combination with growth factors. It has also been
phenotypes associated with skeletal tissue formation. shown to be a weak immunogen (Cooperman and
Further studies aimed at elucidating the various Machaeli, 1984; Johns et al., 1993). Local hemostatic
ADVANCES IN PERIODONTAL REGENERATION 369
Fig. 8. Cells harvested from periodontal soft tissue grown under the membrane barrier and left in
culture for 21 in DMEM medium enriched in 10%serum aggregatedto form nodules (a, c). These cell
cultures heavily stained for BMP-2 at a dilution of 1/50 in PBS (a,c) and BMP-7 at a dilution of 1/50 in
PBS (d).(b)Gingival cell cultures immunostained against BMP-2 (same dilution as above);note absence
of nodule and of any staining. Similar observations were made when gingival fibroblasts were stained
against BMP-7 (not shown). (inverted microscope x 35)
properties in humans of type I collagen have been re- regeneration. Several studies (Pitaru, 1987, 1989;
ported (Stein et al., 1985). Type I collagen represents YafTe, 1987) reported utilizing various forms of type I
the predominant matrix macromolecule of the late collagen as a membrane barrier for guided tissue re-
granulative tissue. generation procedures. Clinical human studies (Chung
et al., 1990; Anderson, 1991) have also demonstrated
Extracellular Matrix in Clinical Application positive results with type I collagen membranes in the
A number of characteristics of matrix macromole- treatment of periodontal defects using guided tissue
cules that may have beneficial effects in clinical appli- regeneration techniques. Mendieta and Williams
cation have been recognized from recent research. This (1994)highlighted in their review the potential of cross-
has led to several reports investigating the use of var- linked type I collagen together with polylactic acid as a
ious components of the ECM to serve as barriers in suitable absorbable membrane. Recently, Pitaru et al.
guided tissue regeneration or biological response mod- (1991) utilized bilayered collagen membrane barriers
ifiers to enhance and/or modulate the healing process enriched with fibronectin and heparan sulphate in bea-
in the treatment of periodontal disease. gle dogs to enhance chemoattraction of healing cells and
Collagen, a major structural component of the ECM, subsequent repopulation of denuded root surfaces while
have been fabricated into suitable absorbable mem- preventing epithelial downgrowth. The next generation
brane barriers that offer considerable advantage over of barrier-membranes used in guided tissue regenera-
the eFTFE membrane advocated in guided tissue re- tion will probably take advantage of the ability of col-
generation procedures. The favorable biological char- lagen to bind growth factors.
acteristics of collagen has led to investigations on its As mentioned earlier, in vitro studies with FN sug-
clinical application in procedures related to periodontal gest several beneficial properties of FN in the ECM
370 S. AMAR
that could be useful in enhancing wound healing. How- Amar, S., P. Petrungaro, A. Amar, and T.E. Van Dyke 1995 Immu-
ever, controversial results have been reported. Animal nolocalization of bone matrix macromolecules in regenerating
human periodontal tissues. Arch. Oral Biol., 40:653-661.
studies (Caffese et al., 1985; Nasjleti et al., 1986; Ryan Amar S., B. Sires, B. Sabsay, J. Clohisy, and A. Veis 1991 The isola-
et al., 1986) showed significantly more connective tis- tion and partial characterization, of a rat incisor dentin matrix
sue reattachment in the treatment of periodontitis polypeptide with in vitro chondrogenic activity. J. Biol. Chem.,
when root surfaces prior to flap closure were coated 266:8609-8818.
Anderson, H.H. 1991 The effectiveness of a collagen membrane bar-
with FN. However, no advantage was observed in ap- rier in achieving new attachment in class I1 furcations. J. Perio.,
plication of exogenous fibronectin above plasma. More 62:718(orban abstract).
research is needed fully to evaluate the influence of Arceo, N., J.J. Sauk, J. Moehring, R.A. Foster, and M.J. Somerman
exogenous fibronectin application on the healing pro- 1991 Human periodontal cells initiate mineral-like nodules in
vitro. J Periodontol, 62(8):499-503.
cess. A number of investigations focused on potential Asahina, I., T.K. Sampath, I., Nishimura, and P.V. Hauschka 1993
beneficial effects of polypeptide growth factors or pleio- Human osteogenic protein-1 induces both chondroblastic and os-
tropic cytokines to explore their potential clinical ap- teoblastic differentiation of osteoprogenitor cells derived from
plication. Lynch et al. (1991) demonstrated that the newborn rat calvaria. J . Cell Biol., 123:921-933.
Aukhil, I., E. Peterson, and C. Suggs 1986 Guided tissue regenera-
application of PDGF and IGF in beagle periodontal de- tion: An experimental procedure in beagle dogs. J. Periodontol.,
fects to enhance periodontal regeneration, whereas Ru- 57:727-734.
therford et al. (1992) reported similar findings in mon- Basilico, C., and D. Moscatelli 1992 The FGF family of growth factors
keys. Bowers et al. (1991) showed that osteogenin and oncogenes. Adv. Cancer Res., 59:115-165.
Baum, C.M., LL. Weissman, A.S. Tsukamoto, A. Buckle, and B.
(BMP-3) combined with demineralized freeze-dried Peault 1992 Isolation of a candidate human hematopoietic stem-
bone allografts significantly enhanced human peri- cell population. Proc. Natl. Acad. Ski. USA, 89:2804-2808.
odontal regeneration in both submerged environment Berenson, R.J., R.G. Andrews, W.I. Bensinger, D.Kalamasz, G. Knit-
free of microbial plaque as well as in the nonsubmerged ter, and C.D. Buckner 1988Antigen CD34 + marrow cells engraft
lethally irradiated baboons. J. Clin. Invest., 81:951-955.
environment. In addition, Ripamonti et al. (1992) dem- Bianco, P., L.W. Fisher, M.F.Young, J.D. Termine, and P.G. Robey
onstrated that BMP-3 adsorbed on porous hydroxyap- 1991 Expression of bone sialoprotein (BSP) in developing human
atite and implanted in critical size calvarial defects tissues. Cal. Tiss. Int., 49:421-426.
induced new bone formation, whereas implantation of Blom, S. 1992 The effect of insulin-like growth factor-1 and human
growth factor on PDL fibroblast morphology, growth pattern and
plain HA resulted in fibrous encaplantation. Recently, DNA svnthesis and receutor bindine. J. Perio.. 63:960-968.
BMP's were used in animal studies in an attempt to Bornstein, P. 1992 Thrombos.pondons: St&cture and regulation of ex-
promote periodontal regeneration. Surgically created pression. FASEB J., 6:3290-3299.
periodontal wound defects treated with BMP-2 or os- Bowers, G., F. Felton, C. Middleton, D. Glynn, S. Sharp, and J. Mel-
lonig 1991 Histologic comparison of regeneration i n human in-
teogenin, in beagles (Sigurdsson et al., 1995) or baboon trabony defects when osteogenin is comboned with freeze-dried
(Ripamonti et al., 1994) significantly enhanced peri- bone allgraft and with purified bovine collagen. J. Perio., 62:690-
odontal regeneration. These studies provide the first 702.
evidence that exogenous growth factors can supple- Cafesse, R., L. Dominguez, C. Nasjleti, W. Castelli, E. Morison, and
ment endogenous ones to participate in the healing cas- regeneration. J. Periodontol., 61:45-5%.
".,
B. Smith 1990 Furcation defects in dogs treated bv a i d e d tissue
cades leading to the expression of tissue-specific phe- Cafesse, R.G., M.J. Holden, S. Kon, and C.E. Nasjleti 1985 The effect
notypes associated with periodontal regeneration. of citric acid and fibronectin auulication on healing following sur-
Future studies promise to reveal significant clinical gical treatment of naturally oc&rring periodontal-disease in bea-
gle dogs. J. Clin. Perio., 12:578-590.
implications in the application of beneficial effects of Canalis, E., T. McCarthy, and M. Centrella 1988 Growth factors and
ECM components to modulate and enhance the local the regulation of bone remodeling. J. Clin. Invest., 80:277-281.
wound microenvironment and achieve predictable peri- Canalis, E., T. McCarthy, and M. Centrella 1991 Growth factors and
odontal regeneration. The use of matrix macromole- cytokines in bone cell metabolism. Ann. Rev. Med., 42:17-24.
Caton, J., and S. Nyman 1981 Histometric evaluation of periodontal
cules to enhance the intrinsic healing potential of peri- surgery. 111. The effect of bone resection on the connective tissue
odontal wounds holds great future in the framework of attachment level. J. Periodontol., 52:405-409.
predictable periodontal regeneration. Management of Caton, J.G., S.Nyman, and H. Zander 1980 Histometric evaluation of
periodontal disease will certainly benefit from these periodontal surgery 11: Connective tissue attachment levels after
four regenerative procedures. J. Clin. Periodontol., 7:224-231.
new developments. Caton, J., C. Wagener, A. Polson, S. Nyman, B. Frantz, and 0. Bouws-
ma 1992 Guided tissue regeneration in interproximal defects in
CONCLUSIONS monkeys. Int. J. Perio. Rest. Dent., 12:267-277.
Celeste, A.J., J.A. Iannazzi, R.C. Taylor, R.M. Hewick, V. Rosen, E.A.
The potential of tissue regeneration through clinical Wang, and J.M. Wozney 1990 Identification of transforming
application of advances made in cell and molecular bi- growth factor beta family members present in bone-inductivepro-
ology is tremendous. The development of advanced tein purified from bovine bone. Proc. Natl. Acad. Sci. USA, 87:
techniques in this field holds promise to provide pow- 984319847,
Centrella. M.. T.L. McCarthy. and E. Canalis 1987 Transforming
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