YIJOM-3763; No of Pages 8

Int. J. Oral Maxillofac. Surg. 2017; xxx: xxx–xxx

http://dx.doi.org/10.1016/j.ijom.2017.02.1279, available online at http://www.sciencedirect.com

Clinical Paper
Dental Implants

Clinical application of T. Minamizato1,a, T. Koga1,a,

Takashi I1, Y. Nakatani1,
M. Umebayashi1, Y. Sumita1,
T. Ikeda2, I. Asahina1
autogenous partially 1
Department of Regenerative Oral Surgery,
Unit of Translational Medicine, Nagasaki
University Graduate School of Biomedical

demineralized dentin matrix Sciences, Nagasaki, Japan; 2Department of

Oral Pathology and Bone Metabolism,
Nagasaki University Graduate School of

prepared immediately after Biomedical Sciences, Nagasaki, Japan

extraction for alveolar bone

regeneration in implant
dentistry: a pilot study
T. Minamizato, T. Koga, Takashi I, Y. Nakatani, M. Umebayashi, Y. Sumita, T. Ikeda,
I. Asahina: Clinical application of autogenous partially demineralized dentin matrix
prepared immediately after extraction for alveolar bone regeneration in implant
dentistry: a pilot study. Int. J. Oral Maxillofac. Surg. 2017; xxx: xxx–xxx. ã 2017
International Association of Oral and Maxillofacial Surgeons. Published by Elsevier
Ltd. All rights reserved.

Abstract. The aim of this study was to examine the efficacy and safety of autogenous
partially demineralized dentin matrix (APDDM) prepared onsite, for clinical
application in bone regeneration procedures related to implant dentistry, including
socket preservation, alveolar ridge augmentation, and maxillary sinus floor
augmentation. In this study, 16 patients underwent dental implant placement using
APDDM transplantation. There were no systemic or local complications (including
surgical site infection) in any of the cases, and oral rehabilitation using dental
implants was successful in all cases for at least 2 years after attachment of the
suprastructure. This report describes the clinical application of APDDM prepared
immediately after tooth extraction to bone augmentation, taking advantage of the
relatively short preparation time due to partial demineralization. APDDM, as Key words: demineralized dentin matrix; alveo-
introduced in this study, is an efficient, safe, and reasonable bone substitute. lar bone augmentation; implant dentistry.
Consequently, this material has the potential to become one of the options as a bone
substitute in implant dentistry. Accepted for publication 14 February 2017

a
Tokutaro Minamizato and Takamitsu Koga contributed equally to this study.

0901-5027/000001+08 ã 2017 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Minamizato T, et al. Clinical application of autogenous partially demineralized dentin matrix
prepared immediately after extraction for alveolar bone regeneration in implant dentistry: a pilot study, Int J Oral Maxillofac Surg
YIJOM-3763; No of Pages 8

2 Minamizato et al.

Oral rehabilitation using dental implants Thus, the aim of the present study was particles, ranging from 400 mm to
has become a highly predictable treatment to examine the efficacy and safety of 800 mm in size, were washed in 1.0 M
option. Accordingly, the demand for alveo- autogenous partially demineralized dentin sodium chloride and partially deminera-
lar bone augmentation is rising with the matrix (APDDM), prepared onsite, for lized in 2% HNO3 (pH 1.0) for 10 min.
increase in indications. Autogenous bone clinical application in alveolar bone re- The APDDM particles were rinsed exten-
grafting remains the gold standard for bone generation procedures related to implant sively twice in 0.1 M Tris–HCl (pH 7.4)
augmentation because it shows excellent dentistry, including socket preservation, for 10 min. This process took approxi-
bone formation1,2. However, it has draw- alveolar ridge augmentation, and maxil- mately 40 min14,15.
backs, including limited availability and lary sinus floor augmentation.
donor site morbidity. Furthermore, the au-
togenous bone graft shows high resorption Transplantation of APDDM and dental
Patients and methods implant placement
rates of up to 50%. Alternative graft mate-
rials including allografts, xenografts, and Patient selection and study design APDDM was transplanted into the defect
alloplastic bone grafts are utilized in the during the same session as the tooth
The Ethics Committee for Clinical Study
clinical setting3, but these also have their extraction. The average defect size was
at Nagasaki University Hospital approved
respective disadvantages, such as potential estimated by computer simulation using
the protocol of this prospective single
disease transmission, high cost, and limited Simplant software (Dentsply Implant,
cohort study. The study was conducted
osteoinduction capability. Hence, an alter- Tokyo, Japan): 0.5–0.6 ml (mean 0.53
between 2011 and 2014 at Nagasaki
native material that overcomes these short- ml) for ridge augmentation, 0.7–1.5 ml
University Hospital. All participants were
comings would be of benefit. (mean 1.1 ml) for socket preservation,
informed about the surgical treatment
It is well known that the structure and and 2.6–4.0 ml (mean 3.3 ml) for sinus
procedure and provided their written in-
composition of dentin is similar to that of floor augmentation. A sufficient volume of
formed consent to participate in the study.
bone, consisting of collagen 20%, hy- APDDM was achieved for the defects in
A total of 16 patients, 10 female and six
droxyapatite 70%, and body fluid 10% all cases, and this was transplanted with
male, aged 25–73 years (mean age 50.0
by weight4. Dentin is thought to have a platelet-rich plasma (PRP). The use of
years), were included in this study. The
high osteoconductivity since it is a natural PRP allows easier handling of the
total number of teeth used for APDDM
mineralized tissue consisting of hydroxy- APDDM, as the particles are bound with
preparation was 25, with an average 1.6
apatite. Furthermore, dentin matrix is the fibrin. Furthermore, PRP is also
per patient. All patients were treated with
expected to exhibit osteoinductivity be- expected to accelerate bone healing.
dental implants.
cause it contains bone morphogenetic pro- Primary closure was achieved after trans-
The subjects were patients who required
teins (BMPs)5. In some patients, tooth plantation in most of the cases, except in
bone augmentation for dental implant
extraction is required before dental im- two cases of socket preservation, in which
treatment, including (1) socket preserva-
plant treatment, and these teeth are usually the wound was covered with a collagen
tion, (2) maxillary sinus floor augmenta-
discarded. It would be beneficial if they membrane to prevent the material from
tion, and (3) alveolar ridge augmentation,
could be utilized as autogenous grafting scattering.
and dental implant placement simulta-
material and thereby avoid the risk of
neous with tooth extraction. A tooth or
disease transmission.
teeth that required extraction as part of the
Several previous studies have examined Histological analysis
dental implant treatment was used in all
the potential of dentin or dentin matrix as a
patients except one, for whom a third A bone biopsy sample was collected using
bone substitute. Some studies using min-
molar was utilized. Patients who had un- a 2.0-mm trephine bur at 4 to 6 months
eralized dentin matrix have shown that the
dergone radiation therapy in the oral and postoperative from the transplanted sites
material possesses excellent biocompati-
maxillofacial region, who had undergone of the patients who underwent socket
bility but is less effective than bone-de-
other bone grafting in the surgical area, or preservation. The specimen was deminer-
rived products in bone formation6,7. On
who had a history of maxillary sinus dis- alized with 10% formic acid after fixation
the other hand, several basic animal stud-
ease or symptoms were excluded. Patients in 10% neutral-buffered formalin. Paraffin
ies have shown demineralized dentin ma-
trix (DDM) to be not only biocompatible,
with any uncontrolled systemic disease sections 6 mm thick were stained with
were also excluded. haematoxylin and eosin (HE) for histolog-
but also osteoinductive, similar to demi-
neralized bone matrix8–10. In terms of ical evaluation. A polarizing microscope
clinical studies, Gomes et al. first reported was used to observe the collagen fibre
the application of autogenous DDM to the
Preparation of autogenous partially structure16.
demineralized dentin matrix (APDDM)
extraction sockets of mandibular third
molars, along with a membrane for guided Both vital and non-vital extracted teeth
Radiological analysis
bone regeneration; they showed superior were used. Following extraction, the soft
healing of the dental sockets with autoge- tissues, calculus, crown restorations, and Bone formation was assessed radiograph-
nous DDM11. Kim et al. applied both root fillings were removed, and the teeth ically at the extraction socket and
mineralized dentin and DDM particles rinsed twice in phosphate buffered saline. maxillary sinus floor using dental and
in dental implant surgery and obtained Next, the teeth were crushed with ice panoramic X-rays obtained immediately
successful bone regeneration results12,13. cubes in a ceramic cup using a specific after the operation, and at 4 weeks, 12
However, most of these studies utilized machine with a high-speed rotation weeks, and >24 weeks after the implanta-
completely demineralized dentin matrix, ceramic blade (Takigen, Japan; interna- tion of APDDM for all patients included
which was difficult to apply at the opera- tional patent application No. PCT/ in this study. Bone formation was
tion site since the preparation of materials JP2007/053321, international published also assessed by computed tomography
takes a long time. No. WO2007/099861 A1). The resulting (CT) (3D Accuitomo F17D; J. Morita

Please cite this article in press as: Minamizato T, et al. Clinical application of autogenous partially demineralized dentin matrix
prepared immediately after extraction for alveolar bone regeneration in implant dentistry: a pilot study, Int J Oral Maxillofac Surg
YIJOM-3763; No of Pages 8

Autogenous partially demineralized dentin matrix 3

Corporation, Kyoto, Japan) at 24 months

postoperative in some patients.

Measurement of dental implant stability

The implant stability quotient (ISQ) was
measured using an Osstell ISQ instrument
(Osstell AB, Gothenburg, Sweden) at 3
months after implant placement. ISQ values
ranging from 1 to 100 were measured in two
directions for each dental implant.

Results
Outcome of socket preservation for
dental implant placement (Table 1) Fig. 1. Socket preservation. In this case, the tooth had to be extracted due to apical periodontitis
(A; arrowhead), and APDDM was transplanted into the socket. Radiopacity was visible in the
Socket preservation with APDDM was socket immediately after surgery since APDDM was not completely demineralized (B; arrow-
applied in seven patients, five female heads). The socket was completely regenerated 6 months postoperatively (C; arrowheads).
and two male, aged 41–63 years (mean Further augmentation was not necessary at dental implant placement.
age 54.6 years). The reasons for tooth
extraction were periodontitis (three teeth
in two patients), root fracture (two teeth in values of 25 to 40 N cm. At second 75, with a mean value of 68.4. The graft
two patients), caries (two teeth in two surgery 3 months after implant placement, sites healed without any notable compli-
patients), and impacted mesiodens (one the ISQ values ranged from 65 to 80, with cations in all cases. No implants were lost
tooth). The site for preservation was molar a mean value of 72.6. The graft sites during 24 months of observation.
in three cases, anterior tooth in three cases, healed without any notable complications The panoramic radiograph obtained at
and premolar in two cases. in all cases. No implants were lost over 24 surgery showed radiopaque dots in the aug-
The immediately prepared APDDM months of observation. mented area (Fig. 2C). Although these dots
was transplanted into the socket in the were still visible at 4 months after surgery,
same session as the tooth extraction. radiopacity in the augmented area had in-
Outcome of maxillary sinus creased and the border between the host
Radiopacity of the APDDM was observed
augmentation (Table 2) bone and the graft had become unclear
at first, since the APDDM was not
completely demineralized (Fig. 1A, B). Sinus floor augmentation with APDDM (Fig. 2D). The vertical height from the
However, the radiopacity of the APDDM was applied in three patients, one female top of the alveolar crest to the sinus floor
decreased gradually and the lamina dura and two male, aged 43–61 years (mean age at the dental implant placement site ranged
surrounding the extraction socket became 50.0 years). Three augmented sites were in from 3.4 mm to 9.5 mm, with a mean height
indistinguishable, although the site was the molar region and two were in the of 7.0 mm before surgery; these values were
still radiolucent, suggesting the progress premolar region. APDDM from each 14.7 mm to 17.1 mm, with a mean height of
of bone remodelling and immature bone tooth was used for augmentation for each 15.7 mm at 3 months postoperative. Radio-
formation. At 4–6 months postoperative, dental implant placement. The reason for graphic examinations revealed that the
the dental implants were placed in the tooth extraction was periodontitis in all vertical height of the augmented area was
socket preservation sites. The height and cases (five teeth in three patients). maintained for 1 year at least. CT images
width of the alveolar ridge were clinically Dental implants were placed simulta- indicated that bone remodelling had
preserved in all cases (Fig. 1C). neously with the augmentation in all progressed at the augmented bone with
A total of eight dental implants were patients, as shown in Fig. 2A, B. All APDDM, since the low density area around
placed in the seven patients after socket implants had initial stability at the time the implant, which was surrounded by a
preservation with APDDM. All implants of placement. The ISQ at second surgery, high density line, seemed to be cancellous
had initial stability, with insertion torque 3 months postoperative, ranged from 65 to bone (Fig. 2E).

Table 1. Characteristics of the subjects and outcomes of socket preservation for dental implant placement.
Implant
Age, Implant Source of Implant length IT ISQ
Patient No. Sex years Diagnosis site APDDM diameter (mm) (mm) (N cm) postoperativea
1 M 41 Impacted mesiodens 11 Impacted mesiodens 4.0 11.0 35 Not detected
2 M 54 Periodontitis 46 46 5.0 9.0 30 68
3 F 50 Periodontitis 35 35 4.1 8.0 35 65
Periodontitis 36 36 4.1 8.0 25 80
4 F 55 Caries 11 11 4.0 10.0 35 75
5 F 56 Root fracture 46 46 4.0 9.0 35 75
6 F 63 Root fracture 21 21 4.0 11.0 30 Not detected
7 F 63 Caries 45 45 4.0 10.0 40 Not detected
APDDM, autogenous partially demineralized dentin matrix; IT, insertion torque; ISQ, implant stability quotient; M, male; F, female.
a
At 3 months postoperative.

Please cite this article in press as: Minamizato T, et al. Clinical application of autogenous partially demineralized dentin matrix
prepared immediately after extraction for alveolar bone regeneration in implant dentistry: a pilot study, Int J Oral Maxillofac Surg
YIJOM-3763; No of Pages 8

4 Minamizato et al.

Table 2. Characteristics of the subjects and outcomes of maxillary sinus floor augmentation.
Preop. vertical Postop. vertical Implant Implant
Patient Age, Implant Source of alveolar height alveolar height diameter length IT ISQ
No. Sex years Diagnosis site APDDM (mm) (mm)a (mm) (mm) (N cm) Postop.a
1 M 46 Periodontitis 25 24+25 9.5 15.1 4.0 13.0 25 65
Periodontitis 26 24+25 8.9 14.9 5.0 11.5 25 70
2 M 61 Periodontitis 27 27 7.5 17.1 5.0 9.0 25 75
3 F 43 Periodontitis 24 24+26 5.5 16.8 4.0 11.5 35 65
Periodontitis 26 24+26 3.4 14.7 4.0 13.0 30 67
APDDM, autogenous partially demineralized dentin matrix; Preop. preoperative; Postop., postoperative; IT, insertion torque; ISQ, implant
stability quotient; M, male; F, female.
a
At 3 months postoperative.

Fig. 2. Sinus floor augmentation. In this case, sinus floor augmentation was required for dental implant placement in the molar region; the teeth
from which APDDM was prepared had to be extracted due to caries and root fracture (A). Sinus floor augmentation with APDDM was performed
using a lateral approach, and dental implants were placed simultaneously (B). The panoramic radiograph obtained after surgery showed
radiopaque dots in the augmented area (C). Although these dots were still visible, the augmented area showed increased radiopacity and the border
between host bone and the graft had become unclear at 3 months after surgery (D). A computed tomography image revealed bone formation around
the dental implant at 24 months postoperative (E).

Outcome of simultaneous alveolar ridge cases of root fracture with buccal wall Examination at high-power magnification
augmentation with implant placement fenestration, as shown in Fig. 3A. The in the rectangular area in Fig. 4A revealed
using APDDM (Table 3) exposed threads of a dental implant (sev- the maturation of new bone with many
eral threads) were covered with APDDM lacunae containing osteocytes (arrow-
Ridge augmentation with simultaneous (Fig. 3B, C). The APDDM was found to heads in 4B), woven bone formation
dental implant placement was applied in have been replaced by bone-like tissue at (labelled ‘c’ in Fig. 4B), and some lining
6 patients, four female and two male, aged second surgery 3 months after dental im- cells on the surface of the newly formed
25–73 years (mean age 53.7 years). Alve- plant placement (Fig. 3D). bone (the square area in Fig. 4B). Exami-
olar bone at a total of 13 sites was aug- The ISQ at second surgery ranged from nation with a polarizing microscope con-
mented with APDDM: one anterior tooth, 65 to 79, with a mean value of 71.6. The firmed that APDDM was surrounded by
and six molar and six premolar sites. In graft sites healed without any notable bone with many collagen fibre-derived
most cases, APDDM was prepared from complications in all cases. No implant lamellar structures (Fig. 4C). Larger mag-
the tooth extracted from the implantation was lost over 24 months of observation. nification of the square area in Fig. 4A
site, but the third molar was utilized in one revealed a lining of osteoblastic cells on
young patient because it was not possible the surface of the bone (arrowheads in
Histological findings
to prepare a sufficient volume of APDDM Fig. 4D). Howship’s lacunae were identi-
from the extracted tooth at the site due to Bone biopsy samples were harvested from fied on the surface of the APDDM, but
severe caries. The reasons for tooth ex- four patients who agreed to have a biopsy. there were very few multinucleated oste-
traction were periodontitis (five teeth in Figure 4 shows HE-stained sections of the oclastic cells (arrowheads in Fig. 4E).
two patients), root fracture (four teeth in sample from a patient who underwent
four patients), and caries (four teeth in socket preservation. New bone formation
Discussion
three patients). (labelled ‘a’ in Fig. 4A) surrounding
The gap between the dental implant and APDDM (labelled ‘b’ in Fig. 4A) was The results of this study demonstrated the
the extraction socket wall, which was over evident, and newly formed bone and efficacy of APDDM as a bone substitute in
1 mm, was filled with APDDM, and the APDDM were found to be amalgamated alveolar bone regeneration related to
technique was specifically applied for at low-power magnification (Fig. 4A). implant dentistry. APDDM showed good

Please cite this article in press as: Minamizato T, et al. Clinical application of autogenous partially demineralized dentin matrix
prepared immediately after extraction for alveolar bone regeneration in implant dentistry: a pilot study, Int J Oral Maxillofac Surg
YIJOM-3763; No of Pages 8

Autogenous partially demineralized dentin matrix 5

Table 3. Characteristics of the subjects and outcomes of simultaneous alveolar ridge augmentation with implant placement using APDDM.
Implant Implant
Age, Implant Source of diameter length IT ISQ
Patient No. Sex years Diagnosis site APDDM (mm) (mm) (N cm) postoperativea
1 M 73 Root fracture 46 46 4.0 11.5 40 68
2 M 61 Periodontitis 14 14 4.5 13.0 30 72
Periodontitis 15 15 4.5 13.0 25 65
Periodontitis 16 16 5.0 9.0 25 73
3 F 25 Caries 45 48 4.0 8.0 40 71
Caries 46 48 4.0 8.0 40 72
Root fracture 47 47 4.0 6.0 45 70
4 F 38 Caries 21 21 4.0 13.0 35 74
Root fracture 44 44 4.0 11.5 45 65
5 F 61 Root fracture 14 14 4.0 11.5 25 75
Caries 15 15 4.0 11.5 25 79
6 F 64 Periodontitis 46 46 4.6 9.0 40 75
Periodontitis 47 47 4.6 7.5 35 72
APDDM, autogenous partially demineralized dentin matrix; IT, insertion torque; ISQ, implant stability quotient; M, male; F, female.
a
At 3 months postoperative.

bone formation both clinically and histo- tivity because the inorganic component of osteoprogenitor cells, is resorbed during
logically. The ISQ at second surgery was dentin consists of hydroxyapatite, which is the bone remodelling process, and accel-
over 60 in all cases, indicating the acqui- the same crystal as in bone7,12. Neverthe- erates bone repair and vessel formation by
sition of stable osseointegration. As a less, organic tissue was exposed at the stimulating the expression of vascular en-
result, oral rehabilitation using dental surface of the APDDM used in this study, dothelial growth factor (VEGF)17. It is
implants was successful in all cases for since the material was partially deminer- also well known that dentin contains
at least 2 years following attachment of the alized, although collagen, the main com- several non-collagenous proteins, includ-
suprastructure. The most important feature ponent of dentin matrix, is a favourable ing osteogenic growth factors such as
for a biomaterial is biocompatibility, and scaffold for cells to attach. In a previous BMPs14,18.
dentin matrix is an ideal material that has basic research study, electron microscopy Once dentin is demineralized, the den-
an affinity for host tissue because it is a revealed the superior attachment of osteo- tinal tubules become wider and expose
natural product. blastic cells to the surface of deminera- dense collagen fibres as a network, serving
Bone substitutes for relatively small lized dentin matrix compared to as a channel for the release of these essen-
bone defects, as shown in this study, are mineralized dentin in vitro15. Further- tial proteins8–10. These proteins might
primarily expected to possess osteocon- more, Reis-Filho et al. reported that show either osteoconductive or osteoin-
ductivity. Dentin has good osteoconduc- DDM has chemotactic properties towards ductive properties. Carvalho et al. reported

Fig. 3. Alveolar ridge augmentation. Alveolar bone dehiscence of the buccal wall was observed (A; arrowhead). Several threads of the dental
implant were exposed at dental implant placement (B; arrowhead). APDDM was transplanted into the defect (C; arrowhead). The alveolar ridge
was augmented and bone-like tissue covered the screw cap (D; arrowhead).

Please cite this article in press as: Minamizato T, et al. Clinical application of autogenous partially demineralized dentin matrix
prepared immediately after extraction for alveolar bone regeneration in implant dentistry: a pilot study, Int J Oral Maxillofac Surg
YIJOM-3763; No of Pages 8

6 Minamizato et al.

Fig. 4. Histological findings. New bone formation (labelled ‘a’ in A, B, and C) surrounding APDDM (labelled ‘b’ in A, B, and C) was evident, and
newly formed bone and APDDM were found to be amalgamated at low-power magnification (A). Examination at high-power magnification of the
rectangular area in (A) revealed maturation of the new bone with many lacunae containing osteocytes (arrowheads in B), woven bone formation
(labelled ‘c’ in B), and some lining cells on the surface of the newly formed bone (the square area in B). Examination with a polarizing microscope
verified that the APDDM was surrounded by bone, with many collagen fibre-derived lamellar structures (C). Larger magnification of the square
area in (A) revealed a lining of osteoblastic cells on the surface of the bone (arrowheads in D). Howship’s lacunae could be identified on the surface
of the APDDM, but there were very few multinucleated osteoclastic cells (arrowheads in E).

that the demineralization of DDM does not oralis, and Enterococcus faecalis23. Addi- which takes only 10 min. Koga et al.
disrupt its osteopromotive properties19. tionally, there is no risk of immune-rejec- reported that demineralization with nitric
DDM is a reservoir of biochemical factors tion or the transmission of infectious acid for 10 min resulted in 70% deminer-
that induce cellular proliferation as well as disease since APDDM is an autogenous alization for particles of around 500 mm in
cell differentiation and chemotaxis. The tissue. size, and this partially demineralized den-
histological examinations in the present There are some drawbacks when using tin matrix had superior bone inductivity
study showed that APDDM was sur- APDDM, including the limited indications compared to completely demineralized
rounded by newly formed bone that was and the issues related to its preparation. dentin matrix or non-demineralized den-
apart from the host bone. This finding This technique cannot be adopted when tin15. The whole procedure for preparation
suggests the possibility that APDDM there is no available tooth that requires takes approximately 40 min. This enables
may have bone inductive activity. extraction or when there are larger bony the grafting of APDDM on site. With
No infection was observed at any of the defects, since the available volume of advances made in dental implants, cases
APDDM implant sites. This might be APDDM is limited. This could be resolved of immediate implant placement after
because demineralization was effective if allogeneic teeth could be utilized, like tooth extraction are increasing. Many of
for antimicrobial activity. Demineraliza- freeze dried allografts and demineralized these cases need bone grafting for fenes-
tion with acid washed away the debris on freeze dried allografts, which are used trations of the socket wall or the space
the surface of the dentin and also acted as widely in clinical practice24,25, although between the dental implant and buccal
an antiseptic. Furthermore, it is also the potential of disease transmission can- wall. The procedure presented in this
reported that dentin contains naturally not be eliminated. Thus, APDDM cannot study could be applied in such cases.
occurring antimicrobial peptides, includ- be used off-the-shelf like allogeneic or PRP was added mainly to promote eas-
ing the neuropeptides substance P, neuro- xenogeneic graft materials and alloplastic ier handling of the APDDM by binding the
kinin A, calcitonin gene-related peptide, materials. particles, but it is possible that the PRP
and adrenomedullin, which may play a The preparation of DDM is time-con- also accelerated the bone regeneration in
role in the host tissue defence against suming. In most clinical studies using this study; PRP is known to promote
infection20–22. Extracellular matrix dentin matrix, approximately 12 h (over- wound healing, including bone regenera-
extracts from dentin also possess antimi- night) has been required for complete tion, by releasing many growth factors26.
crobial activity against indigenous bacte- dentin demineralization. In contrast, par- APDDM and PRP may play different roles
ria in the oral cavity, such as tially demineralized dentin matrix in bone regeneration. Although some stud-
Streptococcus mutans, Streptococcus (APDDM) was utilized in this study, ies have shown successful sinus floor aug-

Please cite this article in press as: Minamizato T, et al. Clinical application of autogenous partially demineralized dentin matrix
prepared immediately after extraction for alveolar bone regeneration in implant dentistry: a pilot study, Int J Oral Maxillofac Surg
YIJOM-3763; No of Pages 8

Autogenous partially demineralized dentin matrix 7

mentation with only a PRP graft in gel Patient consent rat dentin matrix possessing bone morpho-
form27, producing a three-dimensional genetic activity. J Dent Res 1977;56:228–32.
Written patient consent was obtained. 15. Koga T, Minamizato T, Kawai Y, Miura K, T.
configuration appears difficult because
PRP lacks sufficient mechanical strength. I. Nakatani Y, Sumita Y, Asahina I. Bone
On the other hand, APDDM supports regeneration using dentin matrix depends on
References the degree of demineralization and particle
superior bone microstructure in bone
defects as an osteogenic scaffold. Gomes 1. Bauer TW, Muschler CF. Bone graft materi- size. PLoS One 2016;11:e0147235. http://dx.
et al. demonstrated that the newly formed als: an overview of the basic science. Clin doi.org/10.1371/journal.pone.0147235.
Orthop 2000;371:10–27. 16. Numata Y, Nakada H, Sakae T, Kimura-Suda
bone mass and bone mineral density were
2. Von Arx T, Hardt N, Wallkamm B. The TIME H, LeGeros RZ, Kobayashi K, Makimura M.
significantly better in the DDM group
technique: a new technique for localized al- Qualitative study of the new bone formation
when compared with the PRP group in a surrounding the Ti-implant by FTIR and
study evaluating the effects of DDM and veolar ridge augmentation prior to placement
of dental implants. Int J Oral Maxillofac polarizing microscope. J Hard Tissue Biol
PRP in rabbit calvarial surgical defects28. 2008;17:131–40.
Implants 1996;11:387–94.
Accordingly, in this study, APDDM might 17. Reis-Filho CR, Silva ER, Martins AB, Pes-
3. Zizzari VL, Zara S, Tetè G, Vinci R, Gherlone
have played a central role in bone regen- E, Cataldi A. Biologic and clinical aspects of soa FF, Gomes PV, Araujo MS, Miziara MN,
eration and PRP may have accelerated it. integration of different bone substitutes in oral Alves JB. Demineralized human dentin ma-
The present study demonstrated the surgery: a literature review. Oral Surg Oral trix stimulates the expression of VEGF and
clinical application of APDDM, and the Med Oral Pathol Oral Radiol Endod accelerates the bone repair in tooth sockets
results showed successful alveolar bone 2016;122:392–402. of rats. Arch Oral Biol 2011;57:469–76.
regeneration in implant dentistry without 4. Bath-Balogh M, Fehrenbach MJ. Illustrated 18. Kawai T, Urist MR. A bovine tooth derived
any complications. However, this should dental embryology, histology, and anatomy. bone morphogenic protein. J Dent Res
be regarded as a pilot study: this was a 2nd ed. Philadelphia: Elsevier; 2006. 1989;68:1069–74.
single cohort study with a small number of 5. Yeomans JD, Urist MR. Bone induction by 19. Carvalho VA, Tosello Dde O, Salgado MA,
cases with heterogeneous indications. demineralized dentin implanted into oral, os- Gomes MF. Histomorphometric analysis of
Nevertheless, there are other reports that seous and muscle tissues. Arch Oral Biol homogenous demineralized dentin matrix as
have shown favourable results using DDM 1967;12:999–1008. osteopromotive material in rabbit mandibles.
in sinus floor augmentation, guided bone 6. Fugazzotto PA, De Paoli S, Benfenati SP. The Int J Oral Maxillofac Implants 2004;19:679–
regeneration, and socket preservation, al- use of allogenic freeze dried dentin in the 86.
repair of periodontal osseous defects in 20. Awawdeh LA, Lundy FT, Linden GJ, Shaw
though like the present study these have
humans. Quintessence Int 1986;17:488–97. C, Kennedy JG, Lamey PJ. Quantitative
been in the form of case series29. Pang
7. Kim SG, Kim HK, Lim SC. Combined im- analysis of substance P, neurokinin A and
et al. conducted a prospective randomized calcitonin gene-related peptide in gingival
clinical trial testing dentin matrix and plantation of particule dentine, plaster of Par-
is, and a bone xenograft (Bio-Oss) for bone crevicular fluid associated with painful hu-
showed that the grafting of autogenous man teeth. Eur J Oral Sci 2002;110:185–91.
regeneration in rats. J Craniomaxillofac Surg
teeth into extraction sockets for alveolar 21. El Karim I, Lundy FT, Linden GJ, Lamey PJ.
2001;29:282–8.
bone preservation was as effective as 8. Finkelman RD, Mohan S, Jennings JC, Taylor Extraction and radioimmunoassay quantita-
using anorganic bovine bone (Bio- AK, Jepsen S, Baylink DJ. Quantitation of tion of neuropeptide Y (NPY) and vasoactive
Oss)30. Consequently, DDM could be a growth factors IGF-1, SGF/IGF-2, and TGF- intestinal polypeptide (VIP) from human
favourable bone substitute, and APDDM beta in human dentin. J Bone Miner Res dental pulp tissue. Arch Oral Biol
prepared immediately after tooth extrac- 1990;5:717–23. 2003;48:249–54.
tion for bone augmentation, taking advan- 9. Guo W, He Y, Zhang X, Lu W, Wang C, Yu H. 22. Tomson PL, Grover LM, Lumley PJ, Sloan
tage of the relatively short preparation The use of dentin matrix scaffold and dental AJ, Smith AJ, Cooper PR. Dissolution of
time with partial demineralization, has follicle cells for dentin regeneration. Bioma- bio-active dentine matrix components by
the potential to become one of the options terials 2009;30:6708–23. mineral trioxide aggregate. J Dent
as a bone substitute in implant dentistry. 10. Li R, Guo W, Yang B, Guo L, Sheng L, Chen 2007;35:636–42.
G. Human treated dentin matrix as a natural 23. Smith JG, Smith AJ, Shelton RM, Cooper
scaffold for complete human dentin tissue PR. Antibacterial activity of dentin and pulp
regeneration. Biomaterials 2011;32:4523– extracellular matrix extracts. Int Endod J
Funding 38. 2012;45:749–55.
11. Gomes MF, Abreu PP, Morosolli AR, Araujo 24. Simon M, Jovanovic SA, Trisi P, Scarano A,
This study was funded by a Grant-in-Aid
MM, Goulart MD. Densitometric analysis of Piattelli A. Vertical ridge augmentation
for Scientific Research from Japan Society
the autogenous demineralized dentin matrix around dental implants using a membrane
for the Promotion of Science (No. technique and autogenous bone or allografts
on the dental socket wound healing process
26463017). in humans. Int J Periodontics Restorative
in humans. Braz Oral Res 2006;20:323–30.
12. Kim YK, Kim SG, Byeon JH, Lee HJ, Um Dent 1998;18:9–23.
IU, Lim SC. Development of a novel grafting 25. Cammack GV, Nevins M, Clem DS, Hatch
Competing interests material using autogenous teeth. Oral Surg JP, Mellonig JT. Histologic evaluation of
Oral Med Oral Pathol Oral Radiol Endod mineralized and demineralized freeze dried
None. 2010;109:496–503. bone allograft for ridge and sinus augmenta-
13. Lee JY, Kim YK, Yi YJ, Choi JH. Clinical tions. Int J Periodontics Restorative Dent
evaluation of ridge augmentation using au- 2005;25:231–7.
togenous tooth bone graft material. J Korean 26. Picard F, Hersant B, Bosc R, Meningaud JP.
Ethical approval
Assoc Oral Maxillofac Surg 2013;39:156– The growing evidence for the use of platelet-
The Ethics Committee for Clinical Study 60. rich plasma on diabetic chronic wounds: a
at Nagasaki University Hospital approved 14. Butler WT, Mikulski A, Urist MR, Bridges review and a proposal for a new standard
the study protocol (No. 11052368). G, Uyeno S. Noncollagenous proteins of a care. Wound Repair Regen 2015;23:638–43.

Please cite this article in press as: Minamizato T, et al. Clinical application of autogenous partially demineralized dentin matrix
prepared immediately after extraction for alveolar bone regeneration in implant dentistry: a pilot study, Int J Oral Maxillofac Surg
YIJOM-3763; No of Pages 8

8 Minamizato et al.

27. Tajima N, Ohba S, Sawase T, Asahina I. 29. Lee JY, Lee JH, Kim YK. Comparative Address:
Evaluation of sinus floor augmentation with analysis of guided bone regeneration using Izumi Asahina
simultaneous implant placement using plate- autogenous tooth bone graft material with Department of Regenerative Oral Surgery
let-rich fibrin as sole grafting material. Int J and without resorbable membrane. J Dent Unit of Translational Medicine
Oral Maxillofac Implants 2013;28:77–83. Sci 2013;8:281–6. Nagasaki University Graduate School of
28. Gomes MF, Valva VN, Vieria EM, Giannasi 30. Pang KM, Um IW, Kim YK, Woo JM, Kim Biomedical Sciences
LC, Salgado MA, Vilela-Goulart MG. Ho- SM, Lee JH. Autogenous demineralized den- 1-7-1 Sakamoto
mogenous demineralized dentin matrix and tin matrix from extracted tooth for the aug-
Nagasaki 852-8588
Japan
platelet-rich plasma for bone tissue engineer- mentation of alveolar bone defect: a
Tel.: +81 95 819 7701
ing in cranioplasty of diabetic rabbits: bio- prospective randomized clinical trial in com-
Fax: +81 95 819 7705
chemical, radiographic, and histological parison with anorganic bovine bone. Clin Oral E-mail: asahina@nagasaki-u.ac.jp
analysis. Int J Oral Maxillofac Surg Implants Res )2016;(June). http://dx.doi.org/
2016;45:255–66. 10.1111/clr.12885. [Epub ahead of print].

Please cite this article in press as: Minamizato T, et al. Clinical application of autogenous partially demineralized dentin matrix
prepared immediately after extraction for alveolar bone regeneration in implant dentistry: a pilot study, Int J Oral Maxillofac Surg