Demineralized dentin the future substitute for bone tissue:

bibliography review.

Dentina desmineralizada un futuro substituto oseo: revision

bibliografica.

Noelia Madriz Montalván, DDS*1.

1. Cirujano dentista, Facultad de Odontología Universidad Americana (UAM),
Managua, Nicaragua.
noe.madriz14@gmail.com*

ABSTRACT

Los injertos óseos tienen como objetivo aumentar las dimensiones del hueso
alveolar. Entre estos, los injertos autógenos siguen siendo el patrón de oro pues son
los único que tiene capacidad ontogénica, osteoconductiva y osteoinductiva. Sin
embargo, por la alta morbilidad que presenta la zona de extracción de hueso
muchos pacientes se rehúsan a aceptar esta opción de tratamiento. Este problema
se podría evitar si existiera otra zona o manera de extraer un injerto autógeno,
debido a que la dentina y el hueso alveolar tienen similitudes en sus componentes
y proceso de formación se podría considerar la dentina desmineralizada como un
futuro substituto óseo autógeno. Sin embargo, se deberá considerar realizar un
proceso de desmineralización previa para exponer la matriz orgánica, que esta
compuesta en su mayoría de colágeno. Debido a que no existe un articulo reciente
que recopile la información necesaria para obtener un conocimiento global del tema
y sus ventajas y desventajas se decidió realizar la siguiente revisión bibliográfica.

Bone grafting aims to increase the dimensions of the alveolar bone. Among these,
autogenous grafts continue to be the gold standard because they are the only ones
that have osteogenic, osteoconductive and osteoinductive capacity. However, due
to the high morbidity of the bone extraction area, many patients refuse to accept this
treatment option. This problem would be avoided if there was another area or way
of extracting an autogenous graft, because dentine and alveolar bone have many
similarities in their components and formation process, we could consider
demineralized dentine as a future autogenous bone substitute. However, it should
be considered the fact that we need to carry out a previous demineralization process
to expose the organic matrix, which is composed mostly of collagen. Because there
is no recent article that collects the necessary information to obtain a global
knowledge of the subject and its advantages and disadvantages, it was decided to
carry out the following bibliographical review.
PALABRAS CLAVES
Regeneración ósea, sustituto óseo, revisión bibliografía, regeneración tisular

guiada, dentina desmineralizada, injerto óseo, injerto autógeno.

KEY WORDS
Bone regeneration, bone substitute, bibliography review, guided tissue regeneration,

demineralized dentin, bone graft, autogenous graft.

INTRODUCTION

The ideal bone substitute must be osteoconductive, osteoinductive, bio

absorbable and biocompatible. Autogenous bone grafts are, until now, the most

complete material as a substitute because they have the best properties to achieve

guided regeneration (1). However, the need for other bone substitutes has been

considered since they eliminate the morbidity associated with the site of an

autogenous donor, reduce surgical complexity, reduce treatment costs and

improve patient satisfaction (2). Demineralized dentin has osteoinductive and

osteoconductive properties, its most important components, hydroxyapatite and

collagen, which is highly porous and suitable for the regeneration of hard tissues.

(1,2)

There is a large number of in vivo and in vitro studies that prove the

effectiveness of dentine as a bone substitute. However, there is no recent article

that collects the necessary information to obtain a global knowledge of the subject.

and its advantages and disadvantages. It is for that same reason that it was

decided to carry out the following bibliographical review.

Alveolar bone

Alveolar bone is a component of the skeletal system, its function is to

provide support to dental organs. It has a complex morphology that it’s still being

studied. Alveolar bone is made of specialized connective tissue, a calcified matrix

and an organic one. (3)

Alveolar bone loss causes bone defects, that can be either localized or

generalized. They may be congenital, caused by trauma, surgery or some other

pathology such as periodontal disease, this makes dental treatments more difficult

and less successful (4). Sometimes tooth extraction is the only available treatment

option for a tooth with severe bone loss, which results on an even bigger bone defect.

It has been proposed to carry out a guided bone regeneration as a solution for this

problem (5).

Guided Bone Regeneration

Guided bone regeneration is a reconstructive procedure of the alveolar

ridge by using membranes and bone substitutes (6). It is believed that guided bone

regeneration is achieved when osteoprogenitors cells are allowed to exclusively

repopulate the bone defect site by inhibiting or blocking the entrance of non-

ontogenetic tissues (7).

It is recommended to carry out a guided bone regeneration in cases where

there are isolated bone defects o defects related to the placement of an implant,

such as dehiscence, fenestration or defect after extraction (2,6-8).

 To achieve a proper guided bone regeneration, we need: a bone graft and

a membrane. A bone graft is any material or combination of materials that

promotes a reparative bone response while promoting osteogenesis,

osteoinduction and osteoconductivity (9).

Bone grafts

A bone grafts should stablish a stable non-mobile base that allows the release

of grow factors and preserves the blood supply (2,10). There are many different

types of bone grafts, some of them are: xenograft, allograft, autografts, alloplasts

and bioglass, they all have the same purpose of increasing the height and width of

the alveolar bone (11,12). However, among all graft materials, autografts remain the

gold standard, because it is the only material that is osteogenic, that means, it

contains life cells capable of forming bone (13).

Autogenous graft

Autogenous grafts have many advantages when compared to other types of

grafts, they have shorter healing time, lower cost, greater predictability in large

bone defects, provide better bone quality and there is a lack of immune response,

since the graft is taken from the same host (7,14). However, the limited amount of

bone tissue available and the need for a second surgery, compromise the

effectiveness of the treatment and make it harder (14).

Although different methods have been approached to minimize it, its

greatest disadvantage is the morbidity of bone extraction site (7,8). This problem
would be solved if we were able to extract an autogenous graft from another

structure.

Barrier membranes

Guided bone regeneration uses barrier membranes to direct the growth of

new bone and protect it against unwanted tissue interference, so that they do not

grow inside the bone defect (15,16). Using a membrane is necessary because we

need to exclude non-ontogenetic tissues that interfere with bone regeneration, this

is one of the most important principles of guided bone regeneration (16). The bone

graft, by itself, is not strong enough to support soft tissues, therefore, the

therapeutic protocol would be to place a membrane that physically seals the graft

site that we are trying to regenerate and creates a barrier between soft tissue and

bone graft. (17)

Membranes used in guided bone regeneration are manufactured using

different materials, we can classify them as: synthetic polymers, natural polymers,

metals and organic compounds. (2, 7-8)

Among natural polymers we can find collagen membranes (50% of dentinal

tissue is made of it), these are the most common and due to the fact that collagen

is the main component of connective tissue and has a very important role in the

structural support and cell-matrix communication, it has become more and more

appealing to use it during guided bone regeneration process (18).

Demineralized dentin

Demineralized dentin is an absorbable organic material that contains natural

growth factors; after its placement in the body, it absorbs some of the body

proteins. Preventing protein denaturalization is what matters the most during the

demineralization process. It is believed that dentin demineralization helps the

release of growth factors and proteins, and at the same time creates an

osteoinduction process (19).

Different protocols and materials for the preparation of dentin and its use

in bone regeneration have been found, used and debated, among them we have:

(18)

1. Different concentrations of EDTA,

2. Use of phosphoric acid, EDTA, hexamethyldisilazane or lyophilization

3. Demineralization in HCl for one week and chloroform-methanol for one day.

4. Use of 10 minutes of ethanol, freeze drying, use of EDTA or HCl for two weeks.

5. Partial or total lyophilization

6. Soak 10 to 60 minutes in solutions of nitric acid or hydrochloric acid at different

temperatures

7. Use of hydrogen oxide, ethyl alcohol, ethyl ether

Nevertheless, according to Kang-Mi P. et al. (15) in their study, the stored

extracted teeth in 75% alcohol and kept them in a freezer until the sent them to

“Korea Tooth Bank” for processing. Every soft tissue was scraped, teeth were

grounded to form particles of 300 and 800 microns, washed, worn, decalcified and
lyophilized. They were sterilized with ethylene oxide and stored at room

temperature for clinical use.

In the study carried out by Qin X. et al. (16) we are presented with a

different way to carry out dentine demineralization. Sixty-six permanent premolars

without decay were extracted from healthy adult subjects because orthodontic

indications. All the extracted teeth were stored in a 0.5% chloramine solution

immediately after the extraction, the residues were cleaned, all the teeth were cut

in slices, along the occlusal-apical direction, in the form of cuboids to get a block of

medial dentine. Prepared dentin beams were stored in physiological solution at 4°C

for later application. These dentin beams were divided into 5 groups, which

received 0, 6, 12, 24 or 48 hours of exposure to a 0.6 M hydrochloric acid solution,

respectively. The demineralized dentin was stored and its physicochemical

properties were evaluated.

The study concluded that dentin treated with acid for 6 hours has similar

characteristics compared to bone tissue. In this situation, acid etching represents

an easy and promising approach to obtain demineralized dentine with bone like

properties. Acid etching is used to modify the mechanical properties of dentin, it is

relatively easy control, has lower cost than many of the options mentioned above

and is easy to produce in large quantities. The research showed that it does not

matter what type of acid nor how long the teeth is etched, because after acid

etching there is a tendency to decrease intrafibrillar mineralization and increased

exposure of collagen fibrils (16).

Similarities betw een alveolar bone and dentin formation.

Despite the fact that alveolar bone formation is still under investigation

phase, we do know its components and have information, although very basic, of

how its formed. The processes of production of dentin and alveolar bone in the

body have a level of similarity, especially the part of the process before the dentine

is mineralized (3). Dentin is the predominant tissue in the tooth and it also offers

structural support for enamel, it shares many components with bone tissue. Not

only the organic dentine is composed of type I collagen, but most of the skeletal

muscle tissues of the human body are composed of it too, these fibers are

interconnected with macromolecules in a 30% and water in a 20% (19).

Bone tissue and dentin share the same embryonic origin: the neural crest.

They also have a very similar chemical composition, 65% inorganic substances

and 35% organic substances, with type I collagen being the most common

substance in both tissues. In dentin, type I collagen composes 90% of the organic

components, the rest is made up of non-collagen proteins that also participate in

the processes of generation and reabsorption of hard tissues (3, 19).

So far, the packing site and the exocytic route of collagen proteins are not

certain yet. However, it is known that the release of non-collagen proteins seems to

happen mainly at the base of the cell process of osteoblasts and odontoblasts and

that collagen is a fundamental part of the creation of both bone and dentin matrix

(3). Collagenous proteins have the ability to form molecules that adhere in the

extracellular space and promote cell anchoring (4).

 Lysyl oxidase and tyrosine-rich acidic matrix protein are prominent

components of the demineralized bone and dentin matrix. Lysil oxidase is known to

be a critical enzyme for collagen cross-linking and tyrosine possesses cell binding

properties. Tyrosine-rich acid matrix protein binds to decorin and growth factor B.

All these proteins together can regulate the cellular response to transform growth

factor B, which regulates proliferation and differentiation of several different cells,

thus contributing to the formation of hard tissue (2-3, 8).

Due to similarities in their composition and formation process it could be

suspected that demineralized dentin can be used as an autogenous bone

substitute. Nevertheless, a previous demineralization is needed in order to use it as

bone graft material, this with the objective of removing crystalline inorganic

substances and exposing the organic matrix. (4,7-9).

DISCUSSION

Following tooth loss, a reported 25% of total bone width loss and an

overall 4.0-mm decrease in height occur within the first year. If no action is taken,

continued bone loss occurs. On average, 40% to 60% ridge volume loss occurs

within the first 3 years. Ridge augmentation of the deficient osseous ridge is often

necessary for the placement of implants. (20) for that reason, dentists and

investigators are constantly searching for a better way and improved materials to

replace lost bone tissue.

 Sadat Tabatabaei F (18) and Qin X (7) agree on the use of demineralized

dentin as a bone substitute and the fact that it is a less invasive option to the

normally used autogenous grafts (bone taken from the iliac crest or chin). This may

be because there are many indications for extraction of healthy non-decayed teeth,

such as orthodontics and impacted third molars, which would cover both needs in a

single patient. While very few patients agree to undergo an operation to remove

iliac crest bone or chin, since this implies OR time and greater postoperative care.

Both Park S. (4) and Xu Qin (7) agree that the longer dentin is

demineralized, the more organic tissue we will find in it. However, Kabir MA (17)

and Park S. (4) consider that more research and information on the subject is

needed. Authors Misch C., Bono N., Bormann, K.H. and Qin X. (13-16) recognize

that demineralized dentin has a structure similar to that of bone tissue and

therefore support its use as a bone substitute.

CONCLUSSION

Because of dentin components, especially hydroxyapatite and collagen, it

has been established to be a good bone substitute, since it has properties similar

to autogenous grafts without the risks that these involve. Demineralized dentin not

only is osteogenic, but also provides favorable wound healing, increases bone

formation and bone density. Nonetheless, additional studies are needed to

determine certain factors such as time and optimal material for demineralization,

however because all of the above, demineralized dentine if, studied more, can be

considered as a future bone substitute.

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