Reprinted from Till JOUKNAI CM
Volume 47, Number 5, Mm 1976

Osseous Autografts
III. Comparison of Osseous Coagulum-
Bone Blend Implants with Open Curettage.

S. J. FROUM*
M. ORTIZ*
R. T. WITKIN*
R. THALER*
I. W. SCOPP*
S. S. STAHL*

IN A PREVIOUS publication we reviewed studies dealing
with the effects of autogenous grafts of iliac marrow and
cancellous bone or osseous coagulum-bone blend on the
restoration of lost periodontium.1 We noted that similar
levels of osseous regeneration apparently took place
regardless of graft material used. Since that time additional
information has been published concerning the
repair response of infrabony defects following grafting
procedures.1"4 Clinically and histologically it has been
demonstrated that, in certain cases, osseous regeneration
of an infrabony defect takes place without the implantation
of any material.*"8 However, comparison studies of
fill efficacy following the use of various therapeutic
techniques are still limited.'
The purpose of the current investigation was to
clinically evaluate and compare "repair responses" of
human periodontal defects following open debridement
with and without the subsequent implantation of an
osseous coagulum-bone blend graft.

MATERIALS AND METHODS

A total of 75 sites were treated in 28 male patients, 23
to 64 years of age. Every patient consented to take part in
this study. Thirty-seven sites in 23 patients were treated
with osseous coagulum-bone blend implants from intraoral
sources, while 38 sites in 13 patients were treated by
open debridement procedures. In seven of our patients
both procedures were performed at different sites with
similar morphology, (i.e. one-wall, two-wall or three-wall
wide defects of similar configuration). Specifically, 26
such sites were treated in these seven patients. In thirteen
of these areas osseous coagulum-bone blend grafts were
used, while the remaining thirteen areas were treated by
open debridemenl.
* From the Periodonlic Section, Dental Service, New York Veterans
Administration Hospital and the Department of Periodontology, New
York University College of Dentistry, New York, New York.
All individuals selected for this study were patients at
the dental clinic of the Veterans Administration Hospital
in New York City. In addition to periodontitis these
patients suffered from a variety of systemic diseases and,
where necessary, medical clearance was obtained. Presurgical
treatment was similar in all cases, consisting of
oral hygiene instruction, adjustment for occlusal interferences,
root planing and curettage under local anesthesia.
Temporary splinting was employed where mobility exceeded
Class II.
Following initial therapy, clinical and radiographic
evaluations were used to determine whether surgery was
necessary to eliminate the defect. An oral hygiene index
was utilized during initial treatment, and only when the
index approached zero was surgery considered.
Loss of periodontal attachment apparatus was measured
immediately before and during periodontal surgery.
In addition, radiographs and clinical photographs
were also taken of the operative sites. All measurements
were made using a specially-prepared grooved omnivac
stent, fabricated on study models as the fixed reference
point and recorded to the nearest 0.1 mm with a no. 50
endodontic silver point, a locking pliers, and a Boley
guage. Fabrication of the stent and details of the
measurement procedures were previously described.1
Similar measurements, photographs and radiographs
were obtained at the time of reentry.

SURGICAL PROCEDURES

In all cases an inverse bevel full thickness, mucoperiosteal
flap was reflected. Site preparation consisted of
debridement of the osseous defect, root planing to
remove root accretions, and irrigation with isotonic
saline. For purposes of classification, intraosseous defects
were classified according to their predominant
configuration and only those having greater than 2.0 mm
depth were included in this study. After this, in the cases
selected for "open debridement" the flap was coapted
and sutured to insure maximum soft tissue coverage.
After site preparation in the "graft" cases the defect
was overfilled with osseous coagulum-bone blend obtained
from intraoral sources.1 Closure of the defect was
performed in the same manner as in the open debridement
cases.
Regardless of procedure, patients were placed on
antibiotic coverage for 1 week beginning with the day of
surgery.
Reentries were performed 7 to 13 weeks after the
initial surgery in all but one case. (Reentry in this case of
open debridement was performed 25 weeks after initial
surgery).
Measurements, photographs and roentgenograms
were obtained at the time of reentry.
Selection of choice of treatment was based on sequential
selection and donor site availability, with the first
area being treated using a graft and the next area treated
by debridement alone.
287
288 Froum, Ortiz, Witkin, Thaler, Scopp, Stahl
J. Periodomol.
May. 1976
RESULTS
Response to Osseous Coagulum-Bone Blend (Tables I
and II)
Osseous coagulum-bone blend implants were performed
in 37 infrabony lesions. Table I lists the range of
osseous fill of all defeats treated with osseous coagulumbone
blend implants. Fill in the one-wall lesions ranged
from a loss of 0.3 mm to a gain of 5.3 mm. Fill in the
two-wall lesions ranged from 0.9 mm to 6.2 mm. Fill in
the three-wall wide lesions ranged from 2.0 mm lo 6.4
m m.
Table il summarizes the repair trends of all defects
treated with osseous coagulum-bone blend implants.
Among the 37 lesions treated were 15 one-wall, 14
two-wall, and 8 three-wall wide defects. The average fill
of all one-wall defects (initial average depth 3.86 mm,
S. D. 1.60) was 2.42 mm, S. D. 1.40. The average fill of all
two-wall defects (initial average depth 4.15 mm, S.D.
1.44) was 3.21 mm, S.D. 1.34. The average fill in all
three-wall lesions (initial average depth 5.03 mm, S.D.
2.33) was 3.64 mm, S.D. 1.51.
The total average increase in bone height with osseous
coagutum-bone blend graft material was 2.98 mm, S.D.
1.44 whereas the initial intraosseous depth averaged 4.22
mm, S.D. 1.73.
Response to Open Debridement Procedures (Tables III
and IV)
Open debridement was the treatment in 38 infrabony
lesions. Table III lists the range of osseous fill of all
defects treated with open debridement procedures. Fill in
the one-wall lesions ranged from a loss of 1.5 mm to a
gain of 2.0 mm. Fill in the two-wall lesions ranged from a
loss of 0.8 mm to a gain of 2.6 mm. Fill in the three-wall
lesions ranged from l.l mm to 1.7 mm.
Table IV summarizes the repair trends of all defects
treated with open debridement procedures. Among the
38 lesions treated, were 18 one-wall, 15 two-wall, 5
three-wall wide defects. The average fill in all one-wall
lesions (initial average depth ?.10 mm, S.D. 0.76) was
0.16 mm, S.D. 0.84. The average fill in all two-wall
lesions (initial average depth 3.00 mm, S.D. 0.92) was
1.03 mm, S.D. 1.00. The average fill in all three-wall
wide lesions (initial average depth 2.86 mm, S.D. 0.60)
was 1.38 mm, S.D. 0.23.
The total average increase in bone height with open
debridement surgical procedures was 0.66 mm. S.D.
0.80 whereas the initial intraosseous depth averaged 3.03
mm, S.D. 0.80.
Comparison of Fill Following the Use of Osseous
Coagulum-Bone Blend versus Open Debridement According
to Type of Defect (Table V)
A comparison of the above reported repair trends
demonstrated the following:
Greater fill was obtained by the use of a graft than by
debridement alone in one-wall lesions and the difference
was statistically significant (/ = 3.03, P < 0.01).
The difference in osseous fill in two-wall lesions
obtained by the two methods was statistically significant
in favor of the graft filled lesions (/ = 4.77, P < 0.01).
The differences in osseous fill in three-wall wide lesions
also proved statistically significant in favor of the graft
filled lesions (/ = 4.15, P < 0.01).
Combining all defects, greater osseous fill was obtained
by the use of osseous coagulum-bone blend
implants than open debridement procedures (/ = 6.15, P
< 0.01).
Comparison of Fill in Similar Defects Following Use of
Osseous Coagulum-Bone Blend versus Open Debridement
in the Same Host (Table VI)
Thirteen sites were selected in seven patients and
received osseous coagulum-bone blend grafts. Among the
13 lesions were six one-wall and seven two-wall defects.
Thirteen similarly classified sites (six one-wall and seven
two-wall) were selected in these patients and treated by
open debridemenl procedures. The total average fill in
the defects treated by osseous coagulum-bone blend
grafts (initial average depth 3.32 mm, S.D. 0.99) was 2.18
mm, S.D. 0.93. The total average fill in the defects
treated by open debridement (initial average depth 2.55
mm, S.D. 1.53) was 0.75 mm, S.D. 0.91.
TABLE I. The Actual Fill Responses {mm) Recorded at the Time of Reentry of the 15 One- Walt.
14 Two-Wall and X Three-Wall Wide Lesions Treaied with Osseous Coagulum-Bone Blend
1 Wall Lesions 2 Wall Lesions 3 Wall Wide Lesions
0.3
1.2
1.5
1.6
1.6
1.7
zo
2.0
2.5
2.5
3.3
3.4
3.6
4.4
5.3
0.9
1.4
2.0
2.3
2.8
2.8
3.3
3.4
3.7
3.8
4.0
4.0
4.3
6.2
2.0
2.3
2.4
3.0
4.0
4.1
4.9
6.4
Volume 47
Number 5 Osseous Autografts 289
TABLE II. Osseus Fill (mm) in Intraosseous Defects Treated with Osseous Coagulum-Bone Blend
Type of Lesion No. o ' D e f e c t s Imiial Average Depth Average Fill of Defect % Fill
Mean S.D. Mean SD
1 Wall
2Wall
3 Wall
TOTAL
15
1.1
8
3/
3.86mm.
4.15mm.
5.03mm.
4.22mm.
1.60
1.44
2.33
1.73
2.42mm.
3.21mm.
3.64mm.
2.98mm.
1.40
1.34
1.51
1.44
62.7%
77.3%
72.4%
70.6%
TABLE III. The Actual Fill Responses (mm) Recorded al the Time of Reentry of the 18
One-Wall, 15 Two-Wail and 5 Three-Wall Wide Lesions Treated with Open
Debridement Procedures
3 Wall Wide Lesions
1.1
1.3
1.3
1.5
1.7
1 Wall
1.5
0.8
0.6
0.5
0.5
0.4
0.0
0.0
0.1
Lesions
0.2
0.3
0.3
0.5
0.6
0.8
0.9
1.5
2.0
2 Wall
0.8
0.2
0.2
0.2
0.3
0.4
0.4
1.0
Lesions
1.2
1.3
1.9
1.9
2.1
2.5
2.6
1V Osseous Fill (mm) in Intraosseous Defects Treated with Open Debridement Procedures
Type of Lesion No of Defects Initial Average Depth Average Fill of Detect "o Fill
1 Wall
2 Wall
3 Wall
TOTAL
18
28
Mean
3.10
3.00
2.86
3.03
S.D
076
0.92
0.60
0.80
Mean
0.16
1.03
1.38
0-66
S.D.
0.84
1.00
0.23
0.80
5.6%
34.3%
48.3%
21.8%
V. Comparison of Osseous Fill (mm) Following Osseous Coagulum-Bone Blend and Open
Dehridemenl Procedures
Type ol Defect
1 Wall
2 Wall
3 Wall
Fill (mm) Bone Blend
Mean S.D.
2.42 1.40
3.21 1.34
3.64 1.51
Fill (mm) Open Debridement
Mean S.D.
0.16 0.84
1.03 1.00
1.38 0.23
TOTAL 2.98 1.44 0.66 0.80
290 Froum, Ortiz. Witkin, Thaler, Scopp, Stahl
J. Periodoniol.
May 1976
The difference in osseous fill for defects treated by the
two different procedures was statistically significant in
favor of graft filled lesions (/ = 3.95 P < 0.01). This
response takes on additional significance because the
initial average depth of the defects treated by the two
different procedures was not statistically different (t =
1.53).
Comparison of Crestal Resorption with Osseous Coagulum-
Bone Blend and Open Debridemem Procedures.
(Table VII)
In the 37 cases treated by osseous coagulum-bone
blend grafts the average crestal resorption was 0.50 mm,
S.D. 1.21. In the 38 cases treated by open debridement
procedures the average crestal resorption was 0.82 mm,
S.D. 0.67.
The difference in crestal resorption in defects treated
by either osseous coagulum-bone blend implants or open
debridement procedures was not statistically significant
(r = 1.34).
Comparison of Average Depth of Defect at Time of
Reentry with Osseous Coagulum-Bone Blend and Open
Debridement Procedures (Table VIII).
In the 37 sites treated by osseous coagulum-bone blend
grafts the average depth of the intraosseous defect at the
time of reentry was 0.76 mm, S.D. 1.26. In the 38 sites
treated by open debridement procedures the average
depth of the intraosseous defect at the time of reentry was
1.51 mm, S.D. 1.04.
In the 15 one-wall defects treated by graft procedures
the average reentry depth of defect was 0.93 mm, S.D.
1.78. In the 18 one-wall defects treated by open debridement
procedures the average reentry depth of defect was
2.02 mm. S.D. 1.16.
In the 14 two-wall defects treated by graft procedures
the average reentry depth of defect was 0.66 mm, S.D.
0.74. In the 15 two-wall defects treated by open debridement
procedures the average reentry depth was 1.03 mm,
S.D. 0.66.
VI. Comparison of Osseous Fill (mm) Following Osseous Coagulum-Bone Blend and Open
Dehridement Trealmeni in the Same Host with Similar Types of Defects
Bone Blend
Type
6 -
7 -
of
1
- 2
Defect
Wall |
Wall /
No. of
13
Sites
Open
Average Initial
(mm (
Mean S
3.32 0
Debridement
Depth
D.
.99
Average Fill
(mm)
Mean S.D.
2.18 0.93
Type of Defect No. of Sites Average Initial Depth
(mm)
6 - 1 Wall
7 - 2 Wall
13
Mean
2.55
S.D.
1.53
Average Fill
(mm)
Mean S.D.
0.75 0.91
TABLF-: VII. Comparison of Crestal Resorption (mm) Following Useof Osseous Coagulum-Bone
Blend Versus Open Debridemem Procedures
Bone Blend
No. of cases Average Crestal Resorption (mm)
Mean S.D.
37 0.50 1.21
Open Debridement
No. of cases Average Crestal Resorption (mm)
Mean S.D.
38 0.82 0.67
Volume 47
\ilirhcr 5 Osseous Auiograftx 291
In the eight three-wall defects treated by graft procedures
the average reentry depth of defect was 0.59 mm,
S.D. 0.80. In the five three-wall defects treated by open
debridement the average reentry depth was 1.10 mm,
S.D. 0.66.
The average residual depth of intraosseous defects
remaining at the time of reentry was less in graft treated
than open debridement treated sites. The difference was
statistically significant (/ = 2.82, P < 0.05).
DISCUSSION
This study was designed to focus on the question: Is a
graft necessary for osseous regeneration following surgical
debridement in an intraosseous defect?9- 10 A recently
published extensive literature review concluded that
regeneration is possible without osseous grafts" but did
not answer the question: "Does a graft potentiate
regeneration in defects of various morphology?" Specific
studies, however, indicate histological2- 12 '* and
clinical1417 success using autogenous bone grafts. In fact,
Haggerty, et al.18 and Bishop19 concur that "many
investigators have found it (autogenous cancellous bone
and marrow) is the best grafting material available
today."19
Our results suggest that with the exception of narrow
three-wall defects, greater fill was obtained in all defects
when an autogenous osseous coagulum-bone blend graft
was used. These repair trends were similar within the
same patient and between patients. (Figs. IA-C, 2A-C,
3A E, 4A F) Yet, as in our previous publications, again
we must point out that human periodontal defects are not
identical. For example, average initial depth of intraosseous
defects treated with osseous coagulum-bone blend
was 4.22 mm (S.D. 1.73), whereas debridement treated
defects had an average initial depth of 3.03 mm (S.D.
0.80). This variant, although limited, if we consider the
TABU; VIII. Comparison of Crestal Resorption (mm) at Reentry Following the Use of Osseous
Coagulum-Bone Blend or Open Debridement
Bone Blend
No. of
Type of Defect Sites Depth at Reentry
Open Debridement
No. of
Sites Depth at Reentry
1 Wall 15
Mean S.D.
0.93mm 1.78 13
Mean S.D.
2.02mm 1.16
2 Wall 14 0.66mm 0.74 1.03mm 0.66
3 Wall Wide 0.59mm 0.80 1.10mm 0.66
TOTAL 37 0.76mm 1.26 38 1.51mm 1.04
FIGURE 1. A, Preoperative probing oj'an S.I mm pocket on the mesial of the maxillarv left central incisor. B, Exposure of the osseous
defect measuring 3.6 mm during the open debridement procedure. C, Appearance of the probed defect shown in IB at reentry. 10
weeks after initial surgerv. Note the residual defect of 1.3 mm. Crestal resorption of 2.3 mm has taken place but there has been 0 mm
of osseous fill'.
292 Froum, Orliz, Witkin, Thaler, Scopp. Stahl
J. Periodomol.
May. 1976
FIGURE 2. A, Preoperative probing oj an H.I mm pocket on the mesial of the maxillary right lateral incisor in the same patient as
shown in Figure IA . B. Exposure and probing of the osseous defect prior to placement of an osseous coagulum-bone blend graft. The
defect measured SM mm in depth, i , Appearance of the defect shown in 2B at reentry, 10 weeks after initial surgery. Note the
apparent fill and remodeling of the lesion. Although there was 1.4 mm of crestal resorption, 2.5 mm of osseous fill has taken place.
Both sites were initially treated at the same time and reeniered at the same time.
\
FIGURE 3. A, Preoperative soft tissue probing of a 7.0 mm pocket on the mesial of the maxillary left canine. B, Exposure of the
two-wall osseous defect during the open debridement procedure. C. Probing the osseous defect which measured 3.2 mm in depth, D,
Reprobing of pocket just prior to reentry shows a pocket depth of 4.2 mm. E, Probing the 1.2 mm residual defect at the lime of
reentry. 10 weeks after initial surgery. Although 0.3 mm of osseous fill has taken place, the 1.77 mm ofcrestal resorption accounts for
the major decrease in the depth of the defect.
standard deviations, may have influenced the repair
sequence. However, in at least 26 sites (Table VI)
pretreatment depth of intraosseous defect recordings
were similar. Yet the repair responses following grafting
versus debridement were significantly different (/ = 3.95
P < 0.01). Thus, our results are in the nature of case
report evidence. This clinical limitation may also account
for the unusually high standard deviations noted in our
results. They reflect both loss of crest as well as fill which
is routinely observed as a clinical response to the same
therapeutic procedure. It is this range of variability in
human responses20 that frequently produces exceedingly
Volume 47
Number 5 Osseous Autografts 293
high standard deviations in statistical evaluations based
on human case reports.
The present report is the last in a series of clinical and
histologic observations of repair trends following the use
of grafts in human periodontal lesions.1-2 Since identical
measurement techniques were used in all three studies,
we now wish to compare repair responses following the
use of open debridemeni, hip marrow grafts and osseous
coagulum-bone blend grafts. Statistical comparisons of
our results (Table IX), show that both graft materials
demonstrated significantly greater osseous regeneration
than debridement alone. Furthermore, as pointed out in
other studies, osseous coagulum-bone blend grafts
showed similar results to those observed following the use
of hip marrow,14 with the exception of very deep lesions
where hip marrow grafts acted more efficiently.1
Finally, it is important to note that although "fill"
procedures show many advantages, continuous long term
FlGl Ri 4. A, Preoperative probing of a 6.7 mm packet on the distal of the maxillary right second premolar, B. Exposure of the
combination /, 2 wall osseous defect prior to implantation of osseous coagulum-bone blend. The defect measures 5.7 mm in depth. C,
Occlusal view of the defect. D, Reprobing of the pocket jusi prior to reentry shows a pocket depth of 3.6 mm, E. Appearance of the
defect at the time of reentry, 10 weeks after initial surgery. There has been 2.8 mm of osseous fill including 0.3 mm of cresial
apposition. The residual defect measures 1.2 mm in depth. F, Occlusal view of the residual defect at the time of reentry.
IX. Comparison of Osseous Repair Following Hip Marrow Grafts, Osseous Coagulum Grafts or Open Debridemeni
1 Wall
No of
Sites
Marrow Treated
Fill (mm] Fill ';..
4.30 57.3%
Coagulum Bone Blend TriMlcd
No. oi
Situs Fill (mini
15 2.42
Fill'..
62 7%
Dubricteineni Treaied
Fill "..
18 0.16 5.6%
No. of
Sm-s F<(l (mini
2 Wall 3-40 100% 14 3.21 77.3*X. 15 1.03 34.3%
364 7Z.A"A. 1.38
TOTAL 4.36 60.7% 298 70.6% 066 21.8*
294 Frown, Ortiz, Witkin, Thaler, Scopp, Siaht I. Periodoniol,
May, 1976
creslal remodeling occurs regardless of graft or debridement
procedures utilized.12 Therefore, ultimate adaptation
to function at the treated sites can be evaluated only
by long term follow up studies.
SUMMARY
A clinical investigation was undertaken to compare
regeneration of osseous defects following either osseous
coagulum-bone blend grafts or open debridement procedures.
Seventy-five sites in 28 patients were treated by the
two procedures.
The average fill in the 37 intraosseous defects treated
by graft procedures (initial average depth = 4.22 mm,
S.D. 1.73) was 2.98 mm, S.D 1.44.
The average fill in the 38 intraosseous lesions treated
by open debridement procedure (initial average depth =
3.03 mm, S.D. 0.80) was 0.66 mm, S.D. 0.80.
Statistical analysis showed a significant difference (P
< 0.01) in fill patterns between the bone blend and open
debridement responses in favor of graft treated sites.
Therefore greater levels of osseous regeneration apparently
took place in our cases following osseous coagulum-
bone blend autogenous graft procedures than following
open debridement procedures in all types of defects
studied.
REFERENCES
1. Froum, S. J., Thaler, R., Scopp. 1. W., and Stahl, S, S.:
Osseous aulografts, I. Clinical responses of bone hlcnd or hip
marrow grafts. J Periodoniol 46: 515, 1975.
2. Froum, S. J.. Thaler, R., Scopp. I. W., and Stahl, S. S.:
Osseous autografts, II. Histologies! responses to osseous
coagulum-bone bknd grafts. J Periodoniol 46: 656, 1975.
3. Ellegaard, B.. Karring, T., Davies, R., Loe, H.: New
attachment alter treatment of infrabony defects in monkeys. J
periodontnl 45: 36K, 1974.
4. Patur. B.: Osseous defects: Evaluation of diagnostic and
treatment methods. J Periodoniol 45: 523. 1974.
5. Ellegaard, B., Karring, T., Listgarten, M.. Loe, H.: New
attachment after treatment of interradicular lesions. J Periodoniol
44: 209, 1973.
6. Ellegaard, B., and Loe. H.: New attachment of periodontal
tissues after treatment of infrabony lesions. J Periodontol
42: MS, 1971.
7. Prichard, J.: The infrabony technique as a predictable
procedure. J Periodontol 28: 202, 1957.
8. Prichard, J.: Advanced Periodonia! Disease, ed 2, pp
558 565. Philadelphia, W. B. Saunders Co.. 1972.
9. Ibid, p 566.
10. Pfeifer, J. S.: The present status of bone grafts in
periodontal therapy. Dent Clin North Am 13: 201. 1969.
11. Kalkwarf. K. L.: Periodontal new attachment without
the placement of osseous potentiating grafts. Periodont Ah.st
27: 53, 1974.
12. Ross, S. E., and Cohen. D. W.: The fate of an osseous
tissue autograft. Periodonlics 6: 145, 1968.
13. Nabers, C. L., Reed, O. M.. and Hamner, III, J. E :
Gross and histologic evaluation of an autogenous hone graft 57
months postoperatively. J Periodoniol 43: 702. 1972.
14. Hiatt. W. H., and Schallhorn, R. G.: Iniraoral transplants
of cancellous bone and marrow in periodonLal lesions J
Periodontol 44: 194, 1973.
15. Nabers, C. L., and O'Leary. T. J.: Autogenous bone
transplants in the treatment of osseous defects. J Periodoniol
36: 5, 1965.
16. Robinson, R. EL: Osseous coasjulum for bone induclion.
J Periodontol 40: 503, 1969.
17. Rosenberg, M. M.: Free osseous tissue autograft as a
predictable procedure. J Periodontol 42: 145, 1971.
18. Haggerty, P. C. and Maeda, I.: Autogenous bone grafts:
A revolution in the treatment of vertical bone defects. J
Periodontol 42: 626, 1971.
19. Bishop, P. J.: Bone allograft.s. Periodont Abst 21: 52,
1973.
20. Tavtigian. R.: The height of the facial radicular alveolar
crest following apically positioned flap operations. J Periodontol
41:412, 1970.
In Memoriam
Harold G. Amrein
1909 1975
Dr. Amrein, an Associate member since 1957, received his dental training at Pacific
University in San Francisco and took numerous short courses in periodontology. At the
time of death he held the classification of an Academic member, and was 64 years of age.