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Periodontology 2000, Vol. 41, 2006, 196217 Printed in Singapore.

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Copyright Blackwell Munksgaard 2006

PERIODONTOLOGY 2000

Regeneration of periodontal tissues: cementogenesis revisited


M A R G A R I T A Z E I C H N E R -D A V I D

Virtually all types of periodontal disease are caused by periodontal pocket infections, although several other factors, including trauma, aging, systemic diseases, genetics, etc., can contribute to the destruction of the periodontium (1, 18, 31, 52, 60, 107, 128, 127, 194). Repair of the periodontium and the regeneration of periodontal tissues remains a major goal in the treatment of periodontal disease and is an area still in need of major research attention, as recently stated by the American Academy of Periodontology (260). In general, to achieve complete tissue regeneration and repair, it is necessary to recapitulate the process of embryogenesis and morphogenesis involved in the original formation of the tissue. In the case of the periodontium, complete periodontal repair entails de novo cementogenesis, osteogenesis and the formation of periodontal ligament bers. Current strategies for periodontal repair are based on anti-infectious measures such as scaling and root planing, guided tissue regeneration (with or without bone grafts) or the use of growth factors, none of which fully restore the architecture of the original periodontium. Several different approaches involving tissue engineering are currently being explored to achieve complete, reliable and reproducible regeneration of the periodontium. As tissue engineering is dened as the science that develops techniques (based on principles of cell and developmental biology) for fabricating new tissues to replace or regenerate lost tissues (205), it is important to understand the formation of specic tissues, the physico-chemical characteristics of the tissues and the molecular events leading to the normal function of the tissues.

Development of the periodontium


The periodontium can be dened as an intricate mosaic of cells and proteins that is primarily

responsible for the attachment of teeth in the oral cavity (144). Several excellent reviews have been published describing the embryonic lineage of the principal periodontal tissues (cementum, periodontal ligament, gingiva and alveolar bone), as well as the cells and extracellular matrix components of the periodontium (10, 13, 14, 21, 19, 46, 45, 51, 71, 80, 82, 144, 158, 185, 186, 193, 212, 214, 243, 244, 245). Formation of the periodontium is initiated with the process of root formation where, following crown formation, the apical mesenchyme continues to proliferate to form the developing periodontium, while the inner and outer enamel epithelia fuse below the level of the cervical enamel to produce a bilayered epithelial sheath, termed the Hertwigs epithelial root sheath. As these cells divide, there is an apical migration of the Hertwigs epithelial root sheath cells through the underlying dental ectomesenchymal tissues, dividing them into the dental papilla and the dental follicle (Fig. 1). As the root develops, the rst radicular mantle dentin is formed and the epithelial sheath is fenestrated. It is believed that cells of the Hertwigs epithelial root sheath migrate away from the root into the region of the future periodontal ligament where they re-associate to form the Epithelial Rest of Malassez. However, not all Hertwigs epithelial root sheath cells migrate into the periodontal ligament site; a few undergo apoptosis and some remain in the root surface (108). Although it is accepted that the Hertwigs epithelial root sheath plays an important role in root development, the precise nature of its role remains controversial. In 1940, Schour & Massler suggested that the major function of the Hertwigs epithelial root sheath was to induce and regulate root formation, including the size, shape and number of roots (244). Other investigators suggested that the role of the Hertwigs epithelial root sheath was to induce the differentiation

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Fig. 1. Root development and periodontium formation. Histological sections of 7-day postnatal mouse mandibular molars showing the initial development of the root by formation of the Hertwigs epithelial root sheath. At the 14-day postnatal time-point, apical migration of the roots

continues, and there is formation of the periodontium with cementum, periodontal ligament and bone. Am, ameloblasts; C, cementum; D, dentin; Ds, dental sac; HERS, Hertwigs epithelial root sheath; Od, odontoblasts; PDL, periodontal ligament.

of odontoblasts to form the root dentin (183, 182, 222, 243, 251), or to differentiate dental sac cells into cementoblasts (181). The current notion states that Hertwigs epithelial root sheath cells produce the basement membrane containing chemotactic proteins, which serve to direct the migration of precementoblast cells (140, 141, 182, 235, 251) and to induce cementoblast differentiation (191, 232, 234). Amongst the basement membrane molecules are several extracellular matrix proteins, growth factors, enamel proteins and adhesion molecules, such as a collagenous-like protein, known as cementum attachment protein (CAP), which has chemotactic potential capable of recruiting putative cementoblast precursors (11, 149, 156, 196, 275). In the second stage of cementogenesis (when the tooth reaches occlusion and cellular cementum is formed), the proliferation of cells of the Hertwigs epithelial root sheath is considerably reduced, and some cells are entrapped in the newly formed mineral where they may inuence phenotypic changes in the dental sac cells (252). It is also suggested that Hertwigs epithelial root sheath cells undergo epithelialmesen-

chymal transformation to become functional cementoblasts in charge of producing the acellular cementum (251, 275). The gingival tissues appear to be derived from both the oral mucosa and the developing tooth germ (135). It has been suggested that the dental follicle (connective tissue surrounding the developing teeth) gives rise to the broblasts forming the periodontal ligament as well as to the alveolar bone and cementoblasts (45, 136, 186, 243), all of which have a common neural crest origin (34). Therefore, it is postulated that there are different types of cementoblasts: those originating from the Hertwigs epithelial root sheath via epithelialmesenchymal transformation and which form the acellular cementum; and those derived from the dental follicle, which form the cellular cementum (9, 19, 105, 251, 275). It is also believed that progenitors for periodontal ligament, osteoblast and cementoblast cells adopt a paravascular location in the periodontal ligament, and these cells, which exhibit some features of stem cells, can regenerate functional tissues when the need arises (150153, 195). Periodontal

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ligament stem cells have recently been isolated from the human periodontium (162, 224, 225). The Epithelial Rest of Malassez cells remain in the periodontal ligament throughout life, suggesting that they have important, although yet unknown, functions, rather than just being leftover structures. Roles attributed to the Epithelial Rest of Malassez cells range from bad to good. The Epithelial Rest of Malassez cells are held responsible for the formation of periodontal cysts and tumors as a result of periapical inammation associated with pulpal necrosis (26, 57, 77, 176, 226, 242). It has also been suggested that Epithelial Rest of Malassez cells contribute to the formation of the periodontal pocket because of their continuum with the junctional epithelium (176, 238). Some studies report the ability of Epithelial Rest of Malassez cells to resorb bone and extracellular matrix, and thus implicate the cells in root resorption (15, 75, 122). On the other hand, it has also been suggested that the cells of the Epithelial Rest of Malassez may protect the root from resorption (259). The nding of Epithelial Rest of Malassez cells being closely associated with neural endings suggests that they have a role in the development of periodontal ligament innervation (126). Studies performed with 1-hydroxyethylidene-1,1-bisphosphonate, a drug that interferes with homeostasis in the periodontal ligament, showed a severe reduction in the width of the periodontal ligament with the development of ankylosis, which was repaired after discontinuing the administration of 1-hydroxyethylidene-1,1-bisphosphonate (261). As the study did not detect a change in the number of Epithelial Rest of Malassez cells posttreatment, it was suggested that cells of the Epithelial Rest of Malassez are unlikely to play an important part in the homeostasis of, and may not be a prerequisite for, the repair and maintenance of the periodontal ligament. On the other hand, the Epithelial Rest of Malassez cells secrete hyaluronic acid, which contributes to the formation of the loose connective tissue characteristics of the periodontal ligament (155). Cells of the Epithelial Rest of Malassez react to mechanical stress, like that associated with orthodontic tooth movement, by increasing their proliferation rate and cell size (27), and thereby help to maintain the space between the periodontal bone and cementum to avoid ankylosis (134). The increased activity of the Epithelial Rest of Malassez cells is consistent with their putative role on collagen turnover in the periodontal ligament, which is accelerated during tooth movement (241), and during cementum repair in areas of root resorption (24). It is suggested that the Epithelial Rest of Malassez cells

may negatively regulate root resorption and induce acellular cementum formation (56). In addition, cells of the Epithelial Rest of Malassez may help in cementum repair because of their ability to activate matrix proteins, such as amelogenin, which are also expressed during tooth development (76, 81). In summary, based on the information presented, it appears that the developed or adult periodontium retains its potential for repair/regeneration in the form of cells of the Epithelial Rest of Malassez, progenitor cells and stem cells, which can be induced to differentiate into cementoblast, osteoblast or periodontal ligament cells to regenerate periodontal tissues.

Molecular factors involved in periodontal development


It is well known that tooth development is regulated by temporal- and spatial-restricted reciprocal epithelial mesenchymal interactions. A number of genes that play a crucial role in tooth development have been identied and include growth factors and their receptors, such as transforming growth factor b-1 and )2, bone morphogenetic protein-2 and )4 (BMP-2, )4), activins, broblast growth factor-4, )8 and )9 (FGF-4, )8, )9), hepatocyte growth factor, and midkine and transcription factors, such as the homeobox genes (Msx1, Msx2, Dlx1, Dlx2, Dlx3, Otlx2, Barx1), Pax genes (Pax9 and Pax6), and Lef1, Gli2/Gli3 and Shh (40, 100, 192, 249, 274). It has been documented that growth factors are involved in establishing the presence, number, site, size or shape of teeth. The availability of knockout mice has provided critical information on some growth factors that are determinants of early tooth development. However, little information is currently available on the growth and transcription factors involved in the later stages of tooth development, such as root development. Although one can assume that the same epithelial mesenchymal interactions will take place between the Hertwigs epithelial root sheath and the underlying root mesenchyme, and all or some of the same growth factors will be involved in root formation, these issues have been only minimally addressed. Transforming growth factor b-1 and its receptors (58, 59), and BMP-2, )3 and )7 (249), have been identied in cementoblasts, periodontal ligament and alveolar bone, and BMP-2, )4 and MSX-2 have been reported in the Hertwigs epithelial root sheath (266). Fibroblast growth factor-2 (143), receptors for epidermal growth factor (42) and growth hormone (270) have been detected in periodontal tissues. However, the published studies are all descriptive and do not provide

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information as to the function of these growth factors in periodontium development. Furthermore, the transforming growth factor-b1-knockout mouse displays no apparent defects in tooth and root development (39), thus excluding a role for this factor in these processes. On the other hand, by using transgenic mice that express the BMP inhibitor, noggin, driven by the keratin 14 promoter (K14-noggin), we recently demonstrated that BMPs are important for proper root morphogenesis. When the function of BMPs is repressed, the transgenic mice demonstrate a delay in tooth development, lack of enamel formation and abnormally shaped roots (198). Insulin-like growth factor-I receptor has been demonstrated in the Hertwigs epithelial root sheath, and in vitro experiments suggest that insulin-like growth factor-I receptor plays a role in the proliferation and elongation of the Hertwigs epithelial root sheath, which is critical for root development (55). Transcription factors associated with root development include two members of the homeobox family of transcription factors: Dlx2 and Dlx3. The expression of Dlx2 by the Hertwigs epithelial root sheath during root development was demonstrated using Dlx2/LacZ transgenic mice (132). Although these studies are only suggestive of a role of Dlx2 in root development, it was of interest that the Dlx2 knockout mice showed normal teeth, while the Dlx1/Dlx2 knockout mice lacked maxillary molars (253). The involvement of Dlx3 in root development comes from the phenotype expressed by patients affected with the genetic disease, trichodento-osseous syndrome, which presents root defects as well as defects in hair, bone and enamel. A deletion of 4 bp in the Dlx3 gene, which causes a frameshift mutation and premature codon termination, resulting in an altered protein, were identied in a family with tricho-dento-osseous syndrome (199). We recently reported the importance of the N-c transcription factor in root development. N-c knockout mice appear normal, except that they exfoliate their teeth shortly after eruption. These mice show a lack of roots of both mandibular and maxillary teeth, and therefore their teeth have no bone attachment. Histological analysis indicated a normal crown, enamel and dentin formation, and although there is initial formation of the Hertwigs epithelial root sheath and a budding root, no further development occurs of the roots, cementum and periodontal attachment apparatus (239).

Cementum composition
In order to understand the process of cementogenesis, it is important to determine the composition of

cementum. As in bone and dentin, the major component of cementum is collagen (16). The expression of noncollagenous proteins that stimulate cell migration, attachment, proliferation, protein synthesis and mineralization during root formation has been reported by several investigators (38, 142, 147). In the early stages of root development, immunohistochemical techniques have shown the expression of multifunctional proteins, such as laminin and bronectin (140). These proteins, as well as other proteins extracted from cementum (173), are initially believed to function as chemo-attractants. Laminin and bronectin can also function as adhesion proteins, together with tenascin (137), bone sialoprotein (38, 142), osteopontin (25), and a 55-kDa cementumattachment protein (196, 263). The presence of other bioactive proteins, such as enamel-like proteins (235, 234), osteonectin/SPARC (201), and mitogenic factors (157, 269), have also been reported in the cementum. In addition to these proteins, cementoblasts synthesize and secrete several glycosaminoglycans (such as chondroitin-4-sulfate, chondroitin-6-sulfate and dermatan sulfate, and collagen brils), which are present in the cementodentinal junction (88, 264, 265). It has been suggested that cementoblasts exhibit an osteoblast-like, rather than an odontoblastlike, phenotype (25). Odontoblast, osteoblast and cementoblast cells express several matrix proteins, such as osteopontin, bone sialoprotein (BSP), osteonectin, osteocalcin, matrix Gla protein (208) and dentin-matrix-protein 1 (DMP-1) (106). The presence of osteocalcin in cementum is more controversial. Bronckers et al. (25), using immunohistochemistry, reported the presence of osteocalcin on the cellular intrinsic ber cementum (CIFC) and associated cementoblasts (mature), but not in the acellular cementum and its associated cementoblasts. Tenorio et al. (246) reported the presence of osteocalcin in acellular extrinsic ber cementum (AEFC) but not in the associated cementoblasts, while CIFC and associated cementoblasts stained weakly. Bosshardt & Nanci (20) used two different antibodies (OC1 and OC2), which gave different results: OC1 showed reactivity with acellular cementum, while OC2 was negative. Similarly, the presence of DMP-1 has been associated with acellular cementum (275) and cementocytes, but not with cementoblasts (255). It has been suggested that acellular cementum is a unique tissue, while cellular cementum and bone share some similarities, although there are still morphological, functional and biochemical differences between the two tissues (19). The presence of cementum-specic proteins remains questionable, although some putative

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cementum-specic proteins have been invoked: a 55-kDa CAP (263); a mitogenic factor (167); and a 72-kDa protein, CEM-1 (235). However, as the characterization and the sole expression by cementoblasts of these proteins have not been determined, the possible existence of cementum-specic proteins remains unknown. It has been reported that cementoblasts and cementocytes produce high levels of the GLUT-1 monosaccharide transporter, while osteoblasts or osteocytes do not express this protein. These data suggest that GLUT-1 may play a role in cementogenesis and could serve as a biomarker to differentiate between cells of cementoblastic and osteoblastic lineage (124). However, the observed differences in GLUT-1 are quantitative, and GLUT-1 is present in many different cell types. Recently, we reported the isolation of a cementoblastoma-derived protein, CP-23, that is expressed by cementoblasts and some precursor cells present in the periodontal ligament, but not by osteoblasts. The function of the CP-23 protein is currently unknown; however, given its nuclear location, it may be required for cementoblast differentiation and may be used as a marker for cementoblast cells (3). The CP-23 protein is also expressed by Hertwigs epithelial root sheath cells (275). Based on our current knowledge of the development of periodontal tissues, several strategies exist for targeting regenerative therapy, ranging from inducing their own regenerative mechanisms using molecular approaches, or utilizing cells to repopulate and recapitulate the developmental process.

periodontal ligament cells are removed from the cementum or are unable to regenerate, bone tissue invades the periodontal ligament space and establishes a direct connection between the tooth and the wall of the alveolar socket, resulting in ankylosis. The ankylotic, nonexible type of tooth support can lead to loss of function and resorption of the tooth root (13).

Can guided tissue regeneration and bone grafting regenerate cementum?


Nyman et al. (174), using Millipore membranes, introduced the concept of a membrane barrier, which excludes the apical migration of gingival epithelial cells and provides an isolated space for the inwards migration of periodontal ligament cells, osteoblasts and cementoblasts. Guided tissue regeneration was successfully used to aid in the regeneration of lost periodontal tissues caused by periodontitis (67). The rst guided tissue regeneration membranes were nonabsorbable and made of polytetrauoroethylene, such as Gore-Tex. Studies on experimentally induced periodontal defects in monkeys suggested that guided tissue regeneration was capable of inducing the formation of new bone and cementum (4). The second generation of guided tissue regeneration used absorbable membranes made of collagen or polylactic and citric acid (28, 159), which eliminated the need for surgical membrane retrieval (66). Recent systematic reviews indicate that, in the treatment of intrabony and furcation defects, guided tissue regeneration is more effective than open ap debridement. Various barrier types yielded no systematic difference in clinical outcome, but barrier types could explain some heterogeneity in the results. Overall, guided tissue regeneration is consistently more effective than open ap debridement in the gain of clinical attachment and reduction of probing depth in the treatment of intrabony and furcation defects (99, 163). The use of grafting material in combination with guided tissue regeneration seems to improve clinical outcomes for furcation, but not for intrabony defects, when compared with the use of barrier membranes alone. It has also been questioned whether guided tissue regeneration produces true cementum regeneration or only cemental repair. The newly formed cementum has been characterized as a cellular cementum that is usually poorly attached to the dentin surface (125). It is suggested that periodontal healing with guided tissue regeneration therapy occurs in two stages. The rst stage comprises an initial healing phase with the formation of a blood clot, transient root resorption/demineralization,

Strategies for periodontal regeneration/repair


The process of periodontal tissue regeneration starts at the moment of tissue damage by means of growth factors and cytokines released by the damaged connective tissue and inammatory cells. It is well accepted that in order to improve periodontal healing, root planing or root conditioning is a necessary antecedent to mesenchymal cell migration and attachment onto the exposed root surface. Acid treatment, in particular with citric acid, has been found to widen the orices of dentinal tubules, thereby accelerating cementogenesis and increasing cementum apposition and connective tissue attachment. However, a systematic review performed by Mariotti (145) suggested that the use of citric acid, tetracycline or EDTA to modify the root surface provides no clinical signicant benet for regeneration in patients with chronic periodontitis. Conversely, when

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deposition of acellular cementum on the root surface and formation of connective tissue. The second phase comprises a remodeling process, which will result in a regenerated cementum similar to pristine cementum as maturation proceeds over time (69). In conclusion, several clinical studies have demonstrated that guided tissue regeneration is a successful treatment modality for periodontal reconstructive surgery and it has become an accepted procedure in most periodontal practices, either by itself or in combination with other treatment modalities. Autologous bone grafts to repair periodontal osseous defects have been used for many years and different approaches have been the subject of several reviews (165, 209). Bone repair can also be achieved using ceramic materials such as Bioglass, which is a bone-bonding bioactive material that has been widely used for bone healing (110). Studies in monkeys suggested that PerioGlas (synthetic bone particulate) can achieve superior bone repair and cementum regeneration and retard epithelial down-growth compared with other, similar materials (50, 109). Additionally, these materials can be used as scaffolds or to deliver other bioactive molecules to enhance their function. The use of bone grafts, powders or ceramics is quite prevalent in many dental practices. A recent systematic review on the efcacy of bone replacement grafts compared with other interventions in the treatment of periodontal osseous defects was performed by Reynolds et al. (202). Meta-analysis indicated that for the treatment of intrabony defects, bone grafts are effective in reducing crestal bone loss, increasing bone level, increasing clinical attachment level, and reducing probing depth compared with open ap debridement procedures. Histological studies showed that demineralized freeze-dried bone allografts support the formation of a new attachment apparatus in intrabony defects; however, the available data indicate that alloplastic grafts support periodontal repair rather than regeneration, and that the best treatment is a combination of bone grafts with barrier membranes. Nevertheless, these strategies are directed mainly to enhance alveolar bone and periodontal ligament repair and have the problems that they do not address cementogenesis and therefore do not completely regenerate the architecture of the original periodontium.

Molecular approaches for cementum regeneration


Advances in our knowledge of developmental biology, and of the growth factors that initiate and

regulate tooth development and tissue repair, suggests the use of some of these factors for periodontium regeneration (37, 61, 68, 71, 118, 116, 117, 128, 170). Some attachment proteins, such as bronectin (29, 206, 262) or CAP (156, 196), are able to enhance broblast migration, attachment and orientation of the connective tissue to the root surface. New strategies, utilizing growth factors to induce cell migration, proliferation and differentiation, were developed to repopulate the damaged periodontal tissues with periodontal ligament cells (32, 247). It is believed that growth factors play important roles in modulating the proliferation and/or migration and/ or differentiation of structural cells in the periodontium (58, 86, 97, 197, 230). It is suggested that growth factor molecules are produced during cementum formation and then stored in the mature cementum matrix with the potential to induce periodontal repair or regeneration when needed (236). Large-scale production of recombinant growth factors has facilitated in vitro and in vivo studies to determine the efcacy of growth factors in periodontal tissue regeneration. Amongst the growth factors currently being used are platelet-derived growth factor, insulin-like growth factor (36, 63, 92, 138, 188, 210), transforming growth factor-b1 (146), basic broblast growth factor (213), dexamethasone (211) and BMPs (121, 205, 211). However, problems in applying these growth factors for periodontal repair include the nonspecic activity of some factors on different cell lineages in time and space, and the rapid loss of growth factors applied topically (13, 138). It has been shown that both platelet-derived growth factor and insulin-like growth factor-1 can stimulate the proliferation and chemotaxis of periodontal ligament cells, and that the combination of platelet-derived growth factor and insulin-like growth factor-1 can further increase the mitogenic effect (23, 44, 175). In addition to the mitogenic activity, platelet-derived growth factor also appears to stimulate collagen synthesis in periodontal ligament cells (146). Furthermore, dexamethasone has been shown to exert the same effect as insulin-like growth factor-1 on periodontal ligament broblasts, gingival broblasts and pulp broblasts, and may substitute for insulin-like growth factor-1 in the platelet-derived growth factor stimulation of cell proliferation (210). In addition to the previously described effects, platelet-derived growth factor has the capacity to signicantly negate and reverse the inhibitory effects of lipopolysaccharide on the proliferation of human gingival broblasts. Lipopolysaccharide from a variety of gram-negative bacteria is known to inhibit

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gingival broblast proliferation and synthesizing activity, has been implicated in periodontal inammation and may also be responsible for delayed wound healing following periodontal therapy (12). In vivo studies using the beagle dog (natural periodontal disease) and the nonhuman primate (ligatureinduced attachment loss) models showed that the application of platelet-derived growth factor/insulinlike growth factor-1 resulted in signicant amounts of new bone and cementum formation (138, 210). Treatment with insulin-like growth factor-1 alone did not signicantly alter healing compared with controls, while treatment with platelet-derived growth factor alone showed signicant regeneration of attachment. Although there are differences in the response to platelet-derived growth factor/insulin-like growth factor-1, depending on which animal model is used (the osseous response in dogs appears to be greater than that of the nonhuman primate, while new attachment formation appears to be greater in the nonhuman primate than in the dog), there is consistency in promoting periodontal regeneration (63, 64). Rutherford et al. (211) showed that platelet-derived growth factor and dexamethasone, combined with a collagen carrier matrix, induced regeneration of the periodontium in monkeys. It has also been shown that the combination of platelet-derived growth factor and guided tissue regeneration work better than either of the two modalities alone (36, 188). Clinical trials in humans using platelet-derived growth factor/insulin-like growth factor to treat periodontal osseous defects showed that only high doses of these factors gave rise to a statistically signicant increase in alveolar bone formation (92). When platelet-derived growth factor was used in combination with bone allografts to treat Class II furcations and interproximal intrabony defects, histological evaluation showed regeneration of new alveolar bone, cementum, and periodontal ligament (30, 171). Platelet-rich plasma is a fraction of plasma that contains platelet-derived growth factor and transforming growth factor-b (180). An alternative to the use of recombinant growth factors is the use of a platelet gel in combination with demineralized freeze-dried bone allografts (5, 43). The limitations of topical protein delivery to periodontal osseous defects include transient biological activity and bioavailability of platelet-derived growth factor at the wound site. To overcome these limitations, studies have used genetic engineering to transduce cells derived from the periodontium, using adenovirus carrying the platelet-derived growth factor gene to promote sustained release and ensure

biological activity (7, 6, 65). The potential use of gene therapy in vivo to stimulate periodontal tissue regeneration has been studied in large tooth-associated alveolar bony defects in rats. The results showed that the direct gene transfer of platelet-derived growth factor-B stimulates the regeneration of alveolar bone and cementum (104). As stated above, some members of the BMPs are normally expressed during the development of the periodontium, such as BMP-3 and BMP-7/OP-1, which have been localized immunologically in alveolar bone, cementum, and periodontal ligament, whereas BMP-2 was only localized in the alveolar bone (249, 266). Although the exact role of BMPs in the development of the periodontium has not yet been determined, these proteins are good candidates for stimulating periodontal regeneration because of their ability to promote not only osteogenesis but also cementogenesis. The expected role of BMPs in stimulating intramembranous bone formation without an endochondral intermediate may provide greater osteogenic potential than autogenous bone or other bone substitutes (121, 118, 119, 170, 205, 240). Studies indicate that recombinant BMP-2 exerts no effect on the growth and differentiation of human periodontal ligament cells in vitro; however, BMP-2 stimulates alkaline phosphatase activity and parathyroid hormone-dependent 3,5-cyclic adenosine monophosphate (cAMP) accumulation, which are early markers of osteoblast differentiation. Nevertheless, BMP-2 produced no mature osteoblasts, as measured by expression of osteocalcin, and also inhibited 1,25(OH)2D3-induced osteocalcin synthesis in these cells (123). In vitro studies using mouse-derived dental follicle and periodontal ligament cells suggest that BMP-2 induced dental follicle cells to differentiate towards a cementoblast/osteoblast phenotype but had no effect on periodontal ligament cells (278). Paradoxally, BMP-2 was found to inhibit cementoblast cell mineralization in vitro by decreasing the expression of BSP and collagen type 1 (279). In studies of BMP-2 on early wound healing in a rat model of periodontal regeneration, the connective tissue attachment was found to be similar in animals receiving BMP-2 and in controls. However, BMP-2 induced bone formation at some distance from the defect, which indicates the need for a suitable delivery system to maintain the BMP-2 at the site of implantation (120). Other studies suggest that the effects of BMPs may be inuenced by certain factors, such as root surface conditioning, delivery systems, masticatory forces, etc., and that BMP-2 stimulates the proliferation and migration of cells from the adjacent

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periodontal ligament into the wounded area, promoting new cementum formation (119). The expression of both BMP-2 and BMP-7 during periodontal tissue morphogenesis suggests that optimal therapeutic regeneration may require the combined use of the two BMPs. BMP-7-treated molar furcation defects in baboons resulted in substantial cementogenesis, while BMP-2 showed limited cementum formation but greater amounts of mineralized bone and osteoid; however, the combined application did not enhance alveolar bone regeneration or new attachment formation over and above that obtained by separate applications of the two BMPs (207). Recently, it was shown that the application of a synthetic BMP-6 polypeptide to a periodontal fenestration defect in rats resulted in increased formation of new bone and cementum (93). Perhaps the use of other members of the BMP family, such as growth and differentiation factor-5, )6, and )7, might provide better and more complete regenerative outcomes. These factors have been detected during the process of periodontal development at the surfaces of alveolar bone, cementum and periodontal ligament ber bundles (223). Limitations for the regular use of BMPs are the need for high doses, non-specic activity on different cell lineages in time and space, and the rapid loss of topically applied growth factors (13, 138). Some of these problems can be overcome by the use of gene transfer technology. Jin et al. (103) used adenoviruses containing BMP-7 to transduce dermal broblasts that were then used to treat mandibular alveolar bone defects in a rat wound repair model. Their results showed chrondrogenesis, with subsequent osteogenesis, cementogenesis and bridging of the periodontal bone defects, suggesting that this genetic engineering approach may be useful in alveolar bone regeneration. A recent literature review (62) concluded that although promising, there were insufcient data at the present time to conduct a meta-analysis on the effect of growth factors for periodontal repair, and pointed to the need for more clinical trials.

Do enamel-associated proteins regenerate cementum?


Based on the presence of enamel proteins in acellular cementum (133, 235, 182, 233), it was thought that these proteins may play a role in the repair/regeneration of periodontal tissues destroyed by periodontal disease (78). This idea was tested by adding enamel proteins or puried enamel matrix derivative to surgically produced periodontal defects in mon-

keys, followed by histological analysis that showed almost complete regeneration of acellular cementum, rmly attached to the dentin and with collagenous bers extending towards newly formed alveolar bone (79). These studies resulted in a new therapeutic preparation to treat periodontal disease, consisting of hydrophobic enamel matrix proteins extracted from porcine developing enamel, which has been marketed by Biora, Inc., under the name of Emdogain. In the past 8 years, the use of enamel proteins for inducing the formation of cementum, bone and dentin has generated numerous in vivo and in vitro studies, as well as clinical trials, resulting in almost 300 publications. In vitro studies, animal studies and clinical trials are all being conducted simultaneously (60, 70, 83, 154). In vitro studies, using periodontal-associated cells such as periodontal ligament broblasts, osteoblasts, cementoblasts, gingival broblasts, gingival epithelial cells, etc., have been conducted in an attempt to understand the molecular and cellular mechanisms involved in the process of enamel matrix derivativeinduced tissue regeneration. In order for enamel matrix derivative to regenerate periodontal tissues, it will need to exert an effect on proliferation, migration, attachment and/or differentiation of the surrounding periodontal cells, and most studies have measured these parameters, as shown in Table 1. Few studies have tested the effect of enamel matrix derivative on cell migration, but available data suggest an increased migration of periodontal ligament cells, osteoblasts, gingival broblasts and dermal broblasts in response to enamel matrix derivative, with the exception of one study that found no effect on periodontal ligament cells (184). Most studies on the effect of enamel matrix derivative on cell attachment, which generally included periodontal ligament cells, found an increase in cell attachment (184). However, one study found the enamel matrix derivative to have no effect on cell attachment of gingival broblasts (256). A number of studies, which measured the effect of enamel matrix derivative on cell proliferation, have found an increase in cell proliferation in the presence of enamel matrix derivative. However, the proliferative effect was not found in two studies using periodontal ligament cells (41, 256), in two studies using osteoblast cell lines (215, 268) and in one study using gingival broblasts (256). Several studies found an inhibition of cell proliferation when epithelial cells were used (112, 139, 273). These data may explain the clinical observation that application of enamel matrix derivative suppresses the down-growth of junctional

203

204
Migration Attachment Proliferation ND No effect ND ND Yes ND ND ND ND Yes ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND Yes increase No effect Yes increase Yes increase ND Yes increase Yes increase Yes Yes increase Yes Yes increase Yes Yes increase Yes Yes increase ND Yes increase ND Increase cAMP, TGF-b1, IL-6, PDGF-AB Increase OPN Inhibits Col I, de novo expression BSP and OCN, increase BMP2 Inhibits Col I, de novo OCN and BMP3 BSP increase Yes No effect Increase AP and TGF-b1 ND ND ND Yes increase Yes, increase IGF-1 and TGF-b1. No effect on bone phenotype Increase matrix (versican, biglycan, decorin, hyaluronan Yes No difference ND ND Yes increase ND ND Yes increase Yes less AP cementoblast ND ND ND ND ND ND ND ND ND ND ND ND More FGF2 and COX2; less AP and MMP1 ND Yes AP Yes AP, Col, OPN, TGF-b1, OCN and MMPS ND Increase Col, IL-6 and PGHS-2; no effect on OCN and IGF-1 Increase OPN and less OCN No effect Yes decrease Yes, increase AP, OCN, TGB1 ND ND ND Yes- more ND ND ND Yes decrease No Col, AP No effect Yes increase No (Type I col) ND ND ND AP increase osteoblast Yes Differentiation (166) (184) (95) (33) (203) (41) (178) (73) (256) (89) (139) (204) (273) (273) (227) (161) (268) (268) (101) (102) (254) (215) (215)

Table 1. In vitro studies on the effect of enamel protein derivative on cells


Mineralization Reference

Cells

Species

Zeichner-David

Periodontal ligament cells Human

Human

Rat (primary)

Human (primary)

Human (primary)

Human (primary)

Human (primary)

Hu (primary)

Hu (primary)

Hu (primary)

Hu (primary)

P (primary)

Mo (cell line)**

Mo (cell line)

Osteoblasts

Hu (ROS17/2.8)

Hu (primary)

Mo (ST2)

Mo (KUSA/A1)

Mo (primary)

Mo (primary)

Mo (MC3T3-E1)

Hu (2T9 pre-osteoblasts)

Hu (MG63 osteoblast like) ND

Table 1. Continued
Migration ND Yes ND ND ND Yes ND ND Yes ND ND ND ND ND ND

Cells ND ND Yes ND ND ND ND No effect ND ND ND Yes ND ND ND ND ND ND No difference No effect ND Yes increase Increase OPN Yes increase More OPN, Less OCN Yes increase Decrease Ocn Decrease BSP Decrease OCN, increase OPN and OPG ND Yes vascular endothelium. Growth factors Yes ND ND ND ND ND Yes ND ND ND Yes increase ND ND Inhibited Inhibited Yes increase AP. Osteoblast phenotype Increase cAMP and PDGF-AB Increase p21WAF1/cip1; decrease CK-18 Yes increase Increase OPN No effect ND ND ND ND ND ND ND No difference ND Yes increase More ECM Yes increase ND No effect Increase AP and TGF-b1 ND Increase matrix (versican, biglycan, decorin, hyaluronan Yes increase ND Yes double Faster osteogenic ND BSP increase ND Yes more ND ND ND ND No ND ND Inhibits Inhibits Inhibits Inhibits ND Yes increase Increase OPN ND Yes increase ND ND Yes increase Yes, increase AP, OCN, TGB1 ND (215) (89) (204) (228) (115) (203) (73) (256) (89) (115) (72) (204) (74) (254) (258) (17) (72) (160) (203) (177) (113)

Species

Attachment Proliferation

Differentiation

Mineralization Reference

Hu (primary)

Hu (MG63)

P (primary)

Hu (Ros17/28)*

Gingival broblast cells

Rat

Hu (primary)

Hu (primary)

Hu (primary)

Hu (primary)

Rat

Rat

P (primary)

Dental follicle

Mo (SV40)

Cementoblasts

Mo (SV40)

Mo (OCCM-30)*

Mo (OCCM-30)ND

Fibroblasts

Mo (L929)

Rabbit

Human (primary)

Mesenchymal stem cells Hu (C2C12)

Epithelial cells

Hu (HELA)

Hu (SCC25)

(113, 112, 114) (204) (271)

ERM

P (primary)

Endothelial cells

Hu (HUVEC)

Yes increase ND

Regeneration of periodontal tissues: cementogenesis revisited

AP, alkaline phosphatase; BMP, bone matrix protein; BSP, bone sialoprotein; Col, collagen; Hu, human; IGF-1, insulin-like growth factor; IL-6, interleukin-6; MMPS, matrix metalloproteinases; Mo, mouse; ND, not determined; OCN, osteocalcin; OPN, osteopontin; OPG, osteoprotegerin; P, pig; PDGF-AB, platelet derived growth factor AB; PGHS-2, prostaglandin G/H synthase 2; TGF-b1, transforming growth factor b-1. *Mouse recombinant amelogenin. Mouse recombinant ameloblastin. Mouse leucine rich amelogenin peptide (LRAP).

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Zeichner-David

epithelium onto dental root surfaces, a process that frequently interferes with the formation of new connective tissue attachments (79, 78). The majority of available in vitro studies have analyzed the effect of enamel matrix derivative on gene expression and differentiation, and most of these studies found either an increased or a decreased expression of certain transcription and growth factors, extracellular matrix proteins or mineralization-associated proteins in the cells tested. Where mineralization was measured, it was found that enamel matrix derivative induced mineralization of periodontal ligament cells (166), increased mineralization of osteoblasts (268) and gingival broblasts (115), decreased mineralization of cementoblast cells (254) and inhibited the mineralization of dental follicle cells (74). Differences in results amongst studies can be explained by differences in sources and concentrations of enamel matrix derivative and in the cell preparations used. Most studies employed primary cell cultures derived from different patients, which probably contained mixed populations of a variety of cells present in the periodontium. Nevertheless, taken together, these studies suggest that enamel matrix derivative can act as a multipurpose growth factor capable of stimulating the proliferation of mesenchymal cells while inhibiting the cell division of epithelial cells, and can stimulate attachment and phenotypical changes in some cells, while inhibiting matrix production in others. Given the widespread use of Emdogain, and the fact that it is made from an extract of enamel proteins, it is important to identify the actual protein responsible for its function. Studies by Maycock et al. (148) found that, in addition to amelogenin, Emdogain contains metalloproteases and serine proteases. Studies by Kawase et al. (114) demonstrated that porcine enamel matrix derivative contains transforming growth factor-b1 (or a transforming growth factor-b-like substance), and that the action of enamel matrix derivative is mediated by the smad2 signaling pathway. In addition, a neutralizing anti-transforming growth factor-b immunoglobulin blocked the action of enamel matrix derivative on epithelial cells, although it failed to block completely enamel matrix derivative-induced broblastic proliferation, suggesting the presence of more than one growth factor. Iwata et al. (98) isolated the inductive activity of enamel matrix derivative by using chromatography and characterized it as being BMP-2 and BMP-4 using specic antibodies. Furthermore, in the presence of noggin (an inhibitor of BMPs), enamel matrix derivative lost its inductive activity, indicating

that BMPs are the molecules responsible for enamel matrix derivative activity. Although these studies suggest that the action of Emdogain is a result of the presence of contaminating growth factors, other studies have shown that pure recombinant enamel proteins indeed have activity as inducers. The results obtained in our laboratory indicate that mouse recombinant amelogenin can increase attachment and proliferation of mouse periodontal ligament cells in vitro (272, 273). Furthermore, a post-translational modied recombinant ameloblastin, another enamelassociated protein, had an effect similar to that of amelogenin on periodontal ligament cells. Both recombinant amelogenin and ameloblastin can change the phenotype expressed by periodontal ligament cells by inhibiting the expression of collagen type I and inducing de novo expression of osteocalcin. Amelogenin also induced the expression of bone sialoprotein and BMP-2, while ameloblastin induced the de novo expression of BMP-3 (273). These results indicate that both enamel-associated proteins have a modulatory effect on the expression of BMPs, suggesting that perhaps these proteins exert their signaling effect by means of BMPs. Recombinant mouse amelogenin improved osteoblast adhesion (90), and increased the expression of bone sialoprotein and decreased the formation of mineralized nodules in cementoblasts (258). A leucine-rich amelogenin peptide, which exhibited no effect on cell proliferation, down-regulated osteocalcin and up-regulated osteopontin in a dose- and timedependent manner, and inhibited the capacity to form mineral nodules (17). Taken together, these reports point towards a growth factor activity for enamel proteins that may be of importance in periodontal tissue regeneration. Several clinical trials have shown an increase in periodontal attachment and bone formation in individuals treated with Emdogain (54, 85, 87, 154, 179, 200, 217, 216, 218, 219, 277). However, in many of these studies, the results were no better than those obtained with other previously established treatments, such as guided tissue regeneration, which yields better outcomes in the management of deep intrabony periodontal defects (84, 187, 218, 221, 231). Histological studies revealed that treatment with Emdogain is unpredictable, resulting in the formation of cellular cementum rather than acellular cementum, and this cementum was only partially attached to the root surface, similar to the cementum formed with the use of guided tissue regeneration. Furthermore, more bone regeneration occurred by using a guided tissue regeneration procedure than

206

Regeneration of periodontal tissues: cementogenesis revisited

Emdogain (216, 219, 218). Other studies showed no evidence of improvement in radiographic bone level, and surgical re-entry found new tissue with a rubbery consistency and that was not mineralized (189, 190). Experiments in rats, using a wounded rat periodontium model followed by immunohistochemical analysis, showed that Emdogain does not affect the expression of differentiation markers or bone matrix protein synthesis in the repopulation response of wounded rat molar periodontium (35). Systematic studies, using literature reviews and meta-analysis, suggest that treatment with enamel matrix derivative results in signicant variations in clinical outcomes (107). Although Emdogain is able to signicantly improve probing attachment levels and pocket depth reduction, some studies found no evidence of clinically important differences between guided tissue regeneration and Emdogain (47, 62) and reported that guided tissue regeneration is more predictable for cementum and bone regeneration (257). Although animal histological studies with surgically created defects suggest that enamel matrix derivative induces the formation of acellular cemen-

tum and promotes attachment of the supporting periodontal tissues, human histological studies have questioned both the consistency of the histological outcomes and the ability of enamel matrix derivative to predictably stimulate the formation of acellular cementum (107). It appears that following treatment with enamel matrix derivative, a bone-like tissue resembling cellular intrinsic brous cementum is formed (22). Despite the mixed results obtained from both in vitro and in vivo studies, new applications of Emdogain are continuously being reported. Some studies suggest that it has the ability to induce the formation of reparative dentin in pulpotomized teeth (94, 96, 168, 169). It is being used to coat titanium implants with mixed results; one study suggests that there is enhanced formation of trabecular bone (229) while the other found no effect (53). It has also been suggested that enamel matrix derivative can combat bacteria in postsurgical periodontal wounds, which otherwise could hamper wound healing and reduce the outcome of regenerative procedures (8, 172, 220, 237). More recently, an acceleration of skin wound

PLF
Control 14 days HERS-CM Control

PL-7
HERS-CM Control

DPM
HERS-CM

21 days

28 days

35 days

Fig. 2. Effect of Hertwigs epithelial root sheath-conditioned media (HERS-CM) on periodontium-associated cell mineralization. HERS-CM was prepared by growing the cells in Dulbeccos modied Eagles minimal essential medium (DMEM) supplemented with 10% fetal calf serum (FCS) and 100 U/ml of penicillin/streptomycin. Cells were incubated at 39.5C in a humidied atmosphere of 95% air and 5% CO2 for 7 days, after which the media were collected, the protein concentration determined and then lyophilized. Periodontal ligament broblasts (PLF), ce-

mentoblasts (PL-7) and dental papillae mesenchyme broblasts (DPM) were prepared from Immortomouse (275). Cells were grown in differentiation conditions (DMEM supplemented with 10% FCS, 100 U/ml of penicillin/streptomycin, 50 mg/ml of ascorbic acid and 2 mM sodium b-glycerophosphate), with or without (controls) 100 lg of HERS-CM proteins. At different time-points of culture, cells were xed with 70% methanol and 30% acetic acid and stained with Von Kossa to determine mineralization.

207

Zeichner-David

healing in the presence of enamel matrix derivative was reported (160).

Cellular tissue engineering for cementum regeneration


It has long been recognized that a recolonization of periodontal ligament cells onto the root surface is necessary for periodontal ligament regeneration (129, 174). One therapeutic approach proposed the removal of autologous cells from the patients periodontal ligament, culture of the cells in vitro, to place them back onto the exposed root coated with chemoattractant factors, and then to cover the area with an articial basement membrane (247). A pilot study was carried out with four patients, using hydroxyapatite as a vehicle for cell delivery. After 6 months, the treated patients exhibited greater pocket reduction and clinical attachment gain, and less gingival recession, than control patients; however, both groups showed good ll of the osseous defects studied (48, 49, 91). Lekic et al. (130) tracked the fate and differentiation of rat periodontal cells and bone marrow cells transplanted into periodontal wounds in rats using cells constitutively expressing b-galactosidase as a marker. Labeled cells were localized in the periodontal ligament and regenerating alveolar bone and it was suggested that, following a cyclical process of growth and development, both cell types were able to differentiate into periodontal ligament broblasts, osteoblasts and cementoblasts, and to contribute to periodontal regeneration (131). Regeneration of cementum, periodontal ligament and alveolar bone has also been observed using auto-transplantation of bone marrow mesenchymal stem cells into periodontal osseous defects in dogs (111). Similar results have been observed after the application of periodontal ligament cell sheets (2). The ability of cementoblasts and dental follicle cells to promote periodontal regeneration in a rodent periodontal fenestration model was analyzed recently (280). The results indicated that cementoblast-treated and carrier alone-treated defects showed complete bone bridging and periodontal ligament formation; however, no new cementum was formed along the root surface in either group. Puzzling, however, was the fact that no repair, or even osteogenesis, was seen within dental follicle cell-treated defects, even though these cells are believed to be precursors of cementoblasts and to be responsible for alveolar bone formation. As our laboratory has established immortal cell lines for the Hertwigs epithelial root sheath (275) and

the Epithelial Rest of Malassez cells, we are exploring the ability of these cells, or their secreted products, to induce periodontal ligament cells to differentiate into cementoblasts in vitro. When periodontal ligament cells, which do not produce a mineralized extracellular matrix, are grown in the presence of Hertwigs epithelial root sheath conditioned media (HERS-CM), these cells produce a mineralized extracellular matrix, as determined by a positive Von-Kossa staining
Effect of HERS-CM on PLF cell differentiation P BSP 21d 21d + HERS

OCN

OSN

OPN

AP

BMP4

Col1

Actin

Fig. 3. Effect of Hertwigs epithelial root sheath-conditioned media (HERS-CM) on the phenotype of periodontal ligament cells. HERS-CM was prepared as previously described. Periodontal ligament cells were grown under proliferation (P) conditions (in the presence of interferonc at 33C) or differentiation conditions [Dulbeccos modied Eagles minimal essential medium (DMEM) supplemented with 10% fetal calf serum (FCS), 100 U/ml of penicillin/streptomycin, 50 mg/ml of ascorbic acid and 2 mM sodium b-glycerophosphate] with or without (controls) 100 lg of HERS-CM proteins. Cells were collected after 21 days in culture (media were changed every other day), the media were removed, cells were rinsed in phosphate-buffered saline (PBS) and total RNA was extracted for determination of phenotype by using reverse transcriptionpolymerase chain reaction (RTPCR). AP, alkaline phosphatase; BMP-4, bone morphogenetic protein-4; BSP, bone sialoprotein; Col1, collagen type I; OCN, osteocalcin; OPN, osteopontin; OSN, osteonectin.

208

Regeneration of periodontal tissues: cementogenesis revisited

(Fig. 2). This effect is specic for periodontal ligament cells because other types of broblasts, such as those derived from the dental pulp, do not produce a mineralized extracellular matrix, even in the presence of HERS-CM. When cementoblast cells, capable of producing a mineralized extracellular matrix, were grown in the presence of HERS-CM, an acceleration in the formation of mineral was detected. Analysis of the phenotype at the molecular level indicated a de novo induction of the expression of bone sialoprotein and osteocalcin, two markers of mineralization (Fig. 3). These results support the concept that, during root development, the secreted products of the Hertwigs epithelial root sheath induce adjacent cells of the periodontal ligament to differentiate and produce new cementum. However, whether these cells differentiate into cementoblasts or osteoblasts awaits further in vivo experiments.

References
1. Adams DF. Diagnosis and treatment of refractory periodontitis. Curr Opin Dent 1992: 2: 3338. 2. Akizuki T, Oda S, Komaki M, Tsuchioka H, Kawakatsu N, Kikuchi A, Yamato MJ, Okano T, Ishikawa I. Application of periodontal ligament cell sheet for periodontal regeneration: a pilot study in beagle dogs. J Periodontal Res 2005: 40: 245251. 3. Alvarez-Perez MA, Narayanan S, Zeichner-David M, Rodriguez Carmona B, Arzate H. Molecular cloning, expression and immunolocalization of a novel human cementum-derived protein (CP-23). Bone 2006: 38: 409 419. 4. Amar S, Chung KM, Nam SH, Karatzas S, Myokai F, Van Dyke TE. Markers of bone and cementum formation accumulate in tissues regenerated in periodontal defects treated with expanded polytetrauoroethylene membranes. J Periodontal Res 1997: 32: 148158. 5. Anitua E. Plasma rich in growth factors: preliminary results of use in the preparation of future sites for implants. Int J Oral Maxillofac Implants 1999: 14: 529535. 6. Anusaksathien O, Webb SA, Jin QM, Giannobile WV Platelet-derived growth factor gene delivery stimulates ex vivo gingival repair. Tissue Eng 2003: 9: 745756. 7. Anusaksathien O, Jin Q, Zhao M, Somerman MJ, Giannobile WV. Effect of sustained gene delivery of platelet-derived growth factor or its antagonist (PDGF-1308) on tissueengineered cementum. J Periodontol 2004: 75: 429440. 8. Arweiler NB, Auschill TM, Donos N, Sculean A. Antibacterial effect of an enamel matrix protein derivative on in vivo dental biolm vitality. Clin Oral Invest 2002: 6: 205 209. 9. Arzate H, Portilla-Robertson J, Aguilar-Mendoza ME. Recombination of epithelial root sheath and dental papilla cells in vitro. Arch Med Res 1996: 27: 573577. 10. Atkinson ME. The development of the mouse molar periodontium. J Periodontal Res 1972: 7: 255260. 11. BarKana I, Narayanan AS, Grosskop A, Savion N, Pitaru S. Cementum attachment protein enriches putative cementoblastic populations on root surfaces in vitro. J Dent Res 2000: 79: 14821488. 12. Bartold PM, Narayanan AS, Page RC. Platelet-derived growth factor reduces the inhibitory effects of lipopolysaccharide on gingival broblast proliferation. J Periodontal Res 1992: 27: 499505. 13. Beertsen W, McCulloch CAG, Sodek J. The periodontal ligament: a unique, multifunctional connective tissues. Periodontol 2000 1997: 13: 2040. 14. Berkovitz BK. Periodontal ligament: structural and clinical correlates. Dent Update 2004: 31: 4650. 15. Birek C, Heersche JN, Jez D, Brunette DM. Secretion of a bone resorbing factor by epithelial cells cultured from porcine rests of Malassez. J Periodontal Res 1983: 18: 7581. 16. Birkedal-Hansen H, Butler WT, Taylor RE. Proteins from the periodontium. characterization of the insoluble collagens of bovine cementum. Calcif Tiss Res 1977: 23: 3944. 17. Boabaid F, Gibson CW, Kuehl MA, Berry JE, Snead ML, Nociti FH Jr, Katchburian E, Somerman MJ. Leucine-rich amelogenin peptide: a candidate signaling molecule during cementogenesis. J Periodontol 2004: 75: 11261136.

Conclusions
It is obvious that major progress has occurred in the world of biology, medicine and dentistry in the past 30 years, and the management of periodontal disease has beneted from these advances. New knowledge about the etiology and pathogenesis of periodontitis, the relationship of the disease to systemic problems, and advances in genetics, molecular biology, cell biology and biomaterials, have opened the door for new regenerative techniques based upon the tissue engineering approach. Treatment of periodontal disease has evolved from just ghting bacteria to a combined effort to eliminate the offending microorganisms, to arrest the progression of tissue damage and to regenerate lost tissues. Although some of the regenerative techniques have been available for several years, and some have shown promising results, none of the techniques are without problems and none have proven to be 100% effective. Many of the regenerative approaches reviewed in this article are still under assessment and further research is needed to develop cell-based tissue strategies, perhaps using stem cells and biomaterials for delivery of these cells. New scaffold materials, which are being developed, are also needed to address some of the delivery issues (164). What may be concluded from the current status of periodontal regeneration is that, as many investigators have previously stated, there is not going to be one magic solution that can be used to treat all periodontal patients, but rather a combination of different approaches that can be adjusted to t the specic need of individual patients.

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Zeichner-David
18. Borrell LN, Papapanou PN. Analytical epidemiology of periodontitis. J Clin Periodontol 2005: 32: 132158. 19. Bosshardt DD. Are cementoblasts a subpopulation of osteoblasts or a unique phenotype? J Dent Res 2005: 84: 390406. 20. Bosshardt DD, Nanci A. Immunodetection of enamel- and cementum-related (bone) proteins at the enamel-free area and cervical portion of the tooth in rat molars. J Bone Miner Res 1997: 12: 367379. 21. Bosshardt DD, Selvig KA. Dental cementum: the dynamic tissue covering the root. Periodontol 2000 1997: 13: 41 75. 22. Bosshardt DD, Sculean A, Windisch P, Pjetursson BE, Lang NP. Effects of enamel matrix proteins on tissue formation along the roots of human teeth. J Periodontal Res 2005: 40: 158167. 23. Boyan LA, Bhargava G, Nishimura F, Orman R, Price R, Terranova VP. Mitogenic and hemotactic responses of human periodontal ligament cells to the different isoforms of platelet-derived growth factor. J Dent Res 1994: 73: 1593 1600. 24. Brice GL, Sampson WJ, Sims MR. An ultrastructural evaluation of the relationship between epithelial rests of Malassez and orthodontic root resorption and repair in man. Aust Orthod J 1991: 12: 9094. 25. Bronckers ALJJ, Farach-Carson MC, Van Waveren E, Butler WT. Immunolocalization of osteopontin, osteocalcin and dentin sialoproteins during dental root formation and early cementogenesis in the rat. J Bone Mineral Res 1994: 9: 833 841. 26. Browne RM. The pathogenesis of odontogenic cysts: a review. J Oral Pathol 1975: 4: 3146. 27. Brunette DM. Mechanical stretching increases the number of epithelial cells synthesizing DNA in culture. J Cell Sci 1984: 69: 3545. 28. Bunyaratavej P, Wang HL. Collagen membranes: a review. J Periodontol 2001: 72: 215229. 29. Caffesse RG, Holden MJ, Kon S, Nasjleti CE. The effect of citric acid and bronectin application on healing following surgical treatment of naturally occurring periodontal disease in beagle dogs. J Clin Periodontol 1985: 12: 578590. 30. Camelo M, Nevins ML, Schenk RK, Lynch SE, Nevins M. Periodontal regeneration in human Class II furcations using puried recombinant human platelet-derived growth factor-BB (rhPDGF-BB) with bone allograft. Int J Periodontics Restorative Dent 2003: 23: 213225. 31. Caton JG, Quinones CR. Etiology of periodontal diseases. Curr Opin Dent 1991: 1: 1728. 32. Caton JG, DeFuria EL, Polson AM, Nyman S. Periodontal regeneration via selective cell repopulation. J Periodontol 1987: 58: 546552. 33. Cattaneo V, Rota C, Silvestri M, Piacentini C, Forlino A, Gallanti A, Rasperini G, Cetta G. Effect of enamel matrix derivative on human periodontal broblasts: proliferation, morphology and root surface colonization. An in vitro study. J Periodontal Res 2003: 38: 568574. 34. Chai Y, Jiang X, Ito Y, Bringas P, Han J, Rowitch DH, Soriano P, McMahon AP, Sucov HM. Fate of the mammalian cranial neural crest during tooth and mandibular morphogenesis. Development 2000: 127: 16711679. 35. Chano L, Tenenbaum HC, Lekic PC, Sodek J, McCulloch CA. Emdogain regulation of cellular differentiation in wounded rat periodontium. J Periodontal Res 2003: 38: 164174. Cho MI, Lin WL, Genco RJ. Platelet-derived growth factorsmodulated guided tissue regenerative therapy. J Periodontol 1995: 66: 522530. Cochran DL, Wozney JM. Biological mediators for periodontal regeneration. Periodontol 2000 1999: 19: 4058. DErrico JA, Macneil RL, Takata T, Berry J, Strayhorn C, Somerman MJ. Expression of bone associated markers by tooth root lining cells, in situ and in vitro. Bone 1997: 20: 117 126. DSouza RN, Cavender A, Sood R, Tarnuzzer R, Dickinson DP, Roberts A, Letterio J. Dental abnormalities in mice lacking a functional transforming factor-beta 1 (TGF-b1) gene indicate a role for TGF-b1 in biomineralization. Int J Oral Biol 1998: 23: 119131. Dassule HR, Lewis P, Bei M, Maas R, McMahon AP. Sonic hedgehog regulates growth and morphogenesis of the tooth. Development 2000: 127: 47754785. Davenport DR, Mailhot JM, Wataha JC, Billman MA, Sharawy MM, Shrout MK. Effects of enamel matrix protein application on the viability, proliferation, and attachment of human periodontal ligament broblasts to diseased root surfaces in vitro. J Clin Periodontol 2003: 30: 125131. Davideau JL, Sahlberg C, Blin C, Papagerakis P, Thesleff I, Berdal A. Differential expression of the full-length and secreted truncated forms of EGF receptor during formation of dental tissues. Int J Dev Biol 1995: 39: 605615. De Obarrio JJ, Arauz-Dutari JI, Chamberlain TM, Croston A. The use of autologous growth factors in periodontal surgical therapy: platelet gel biotechnology case reports. Int J Periodontics Restorative Dent 2000: 20: 486497. Dennison DK, Vallone DR, Pinero GJ, Rittman B, Caffesse RG. Differential effect of TGF-beta 1 and PDGF on proliferation of periodontal ligament cells and gingival broblasts. J Periodontol 1994: 65: 641648. Diekwisch TG. The developmental biology of cementum. Int J Dev Biol 2001: 45: 695706. Diekwisch TG. Pathways and fate of migratory cells during late tooth organogenesis. Connect Tissue Res 2002: 43: 245 56. Esposito M, Coulthard P, Worthington HV. Enamel matrix derivative (Emdogain) for periodontal tissue regeneration in intrabony defects. Cochrane Database Syst Rev 2003: CD003875. Feng F, Hou LT. Treatment of osseous defects with broblast-coated hydroxylapatite particles. J Formos Med Assoc 1992: 91: 10681074. Feng F, Liu CM, Hsu WC, Hou LT. Long-term effects of gingival broblast-coated hydroxylapatite graft on periodontal osseous defects. J Formos Med Assoc 1995: 94: 494 498. Fetner AE, Hartigan MS, Low SB. Periodontal repair using PerioGlas in nonhuman primates: clinical and histologic observations. Compendium. 1994: 15: 935938. Fong HK, Foster BL, Popowics TE, Somerman MJ. The crowning achievement: getting to the root of the problem. J Dent Educ 2005: 69: 555570. Fowler EB, Breault LG, Cuenin MF. Periodontal disease and its association with systemic disease. Mil Med 2001: 166: 8589.

36.

37. 38.

39.

40.

41.

42.

43.

44.

45. 46.

47.

48.

49.

50.

51.

52.

210

Regeneration of periodontal tissues: cementogenesis revisited


53. Franke Stenport V, Johansson CB. Enamel matrix derivative and titanium implants. J Clin Periodontol 2003: 30: 359363. 54. Froum SJ, Weinberg MA, Rosenberg E, Tarnow D. A comparative study utilizing open ap debridement with and without enamel matrix derivative in the treatment of periodontal intrabony defects: a 12-month re-entry study. J Periodontol 2001: 72: 2534. 55. Fujiwara N, Tabata MJ, Endoh M, Ishizeki K, Nawa T. Insulin-like growth factor-I stimulates cell proliferation in the outer layer of Hertwigs epithelial root sheath and elongation of the tooth root in mouse molars in vitro. Cell Tissue Res 2005: 320: 6975. 56. Fujiyama K, Yamashiro T, Fukunaga T, Balam TA, Zheng L, Takano-Yamamoto T. Denervation resulting in dentoalveolar ankylosis associated with decreased Malassez epithelium. J Dent Res 2004: 83: 625629. 57. Gao Z, Mackenzie IC, Rittman BR, Korszun AK, Williams DM, Cruchley AT. Immunocytochemical examination of immune cells in periapical granulomata and odontogenic cysts. J Oral Pathol 1988: 17: 8490. 58. Gao J, Symons AL, Bartold PM. Expression of transforming growth factor-beta 1 (TGF-beta1) in the developing periodontium of rats. J Dent Res 1998: 77: 17081716. 59. Gao J, Symons AL, Bartold PM. Expression of transforming growth factor-beta receptors types II and III within various cells in the rat periodontium. J Periodontal Res 1999: 34: 113122. 60. Gestrelius S, Lyngstadaas SP, Hammarstrom L. Emdogain periodontal regeneration based on biomimicry. Clin Oral Invest 2000: 4: 120125. 61. Giannobile WV. Periodontal tissue engineering by growth factors. Bone 1996: 19: 23S37S. 62. Giannobile WV, Somerman MJ. Growth and amelogeninlike factors in periodontal wound healing. A systematic review. Ann Periodontol 2003: 8: 193204. 63. Giannobile WV, Finkelman RD, Lynch SE. Comparison of canine and nonhuman primate animal models for periodontal therapy. Results following a single administration of PDGF/IGF-I. J Periodontol 1994: 65: 11581168. 64. Giannobile WV, Hernandez RA, Finkelman RD, Ryan S, Kiritsy CP, DAndrea M, Lynch SE. Comparative effects of platelet-derived growth factor-BB and insulin-like growth factor-I, individually and in combination, on periodontal regeneration in Macaca fascicularis. J Periodontal Res 1996: 31: 30112. 65. Giannobile WV, Lee CS, Tomala MP, Tejeda KM, Zhu Z. Platelet-derived growth factor (PDGF) gene delivery for application in periodontal tissue engineering. J Periodontol 2001: 72: 815823. 66. Gottlow J. Guided tissue regeneration using bioresorbable and non-resorbable devices: initial healing and long-term results. J Periodontol 1993: 64: 11571165. 67. Gottlow J, Nyman S, Karring T, Lindhe J. New attachment formation as the result of controlled tissue regeneration. J Clin Periodontol 1984: 11: 494503. 68. Graves DT, Kang YM, Kose KN. Growth factors in periodontal regeneration. Compend Suppl 1994: 18: S672S677. 69. Graziani F, Laurell L, Tonetti M, Gottlow J, Berglundh T. Periodontal wound healing following GTR therapy of dehiscence-type defects in the monkey: short-, medium- and long-term healing. J Clin Periodontol 2005: 32: 905914. 70. Greenstein G. Emdogain: evidence of efcacy. Compend Contin Educ Dent 2000: 21: 299305. 71. Grzesik WJ, Narayanan AS. Cementum and periodontal wound healing and regeneration. Crit Rev Oral Biol Med 2002: 13: 474484. 72. Gurpinar A, Onur MA, Cehreli ZC, Tasman F. Effect of enamel matrix derivative on mouse broblasts and marrow stromal osteoblasts. J Biomater Appl 2003: 18: 2533. 73. Haase HR, Bartold PM. Enamel matrix derivative induces matrix synthesis by cultured human periodontal broblast cells. J Periodontol 2001: 72: 341348. 74. Hakki SS, Berry JE, Somerman MJ. The effect of enamel matrix protein derivative on follicle cells in vitro. J Periodontol 2001: 72: 679687. 75. Hamamoto Y, Nakajima T, Ozawa H. Ultrastructural and histochemical study on the morphogenesis of epithelial rests of Malassez. Arch Histol Cytol 1989: 52: 6170. 76. Hamamoto Y, Nakajima T, Ozawa H, Uchida T. Production of amelogenin by enamel epithelium of Hertwigs root sheath. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996: 81: 703709. 77. Hamamoto Y, Hamamoto N, Nakajima T, Ozawa H. Morphological changes of epithelial rests of Malassez in rat molars induced by local administration of N-methylnitrosourea. Arch Oral Biol 1998: 43: 899906. 78. Hammarstrom L. Enamel matrix, cementum development and regeneration. J Clin Periodontol 1997: 24: 658 668. 79. Hammarstrom L, Heijl L, Gestrelius S. Periodontal regeneration in a buccal dehiscence model in monkeys after application of enamel matrix proteins. J Clin Periodontol 1997: 24: 669677. 80. Harrison JW, Roda RS. Intermediate cementum. Development, structure, composition, and potential functions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995: 79: 624 633. 81. Hasegawa N, Kawaguchi H, Ogawa T, Uchida T, Kurihara H. Immunohistochemical characteristics of epithelial cell rests of Malassez during cementum repair. J Periodontal Res 2003: 38: 5156. 82. Hassell TM. Tissues and cells of the periodontium. Periodontol 2000 1993: 3: 938. 83. Heard RH, Mellonig JT. Regenerative materials: an overview. Alpha Omegan 2000: 93: 5158. 84. Heden G, Wennstrom J, Lindhe J. Periodontal tissue alterations following Emdogain treatment of periodontal sites with angular bone defects. A series of case reports. J Clin Periodontol 1999: 26: 855860. 85. Heijl L. Periodontal regeneration with enamel matrix derivative in one human experimental defect. A case report. J Clin Periodontol 1997: 24: 693696. 86. Helder MN, Karg H, Bervoets TJ, Vukicevic S, Burger EH, DSouza RN, Woltgens JH, Karsenty G, Bronckers AL. Bone morphogenetic protein-7 (osteogenic protein-1, OP-1) and tooth development. J Dent Res 1998: 77: 545554. 87. Hirooka H. The biologic concept for the use of enamel matrix protein: true periodontal regeneration. Quintessence Int 1998: 10: 621630. 88. Ho SP, Sulyanto RM, Marshall SJ, Marshall GW. The cementum-dentin junction also contains glycosaminoglycans and collagen brils. J Struct Biol 2005: 151: 6978.

211

Zeichner-David
89. Hoang AM, Oates TW, Cochran DL. In vitro wound healing responses to enamel matrix derivative. J Periodontol 2000: 71: 12701277. 90. Hoang AM, Klebe RJ, Steffensen B, Ryu OH, Simmer JP, Cochran DL. Amelogenin is a cell adhesion protein. J Dent Res 2002: 81: 497500. 91. Hou LT, Tsai AY, Liu CM, Feng F. Autologous transplantation of gingival broblast-like cells and a hydroxylapatite complex graft in the treatment of periodontal osseous defects: cell cultivation and long-term report of cases. Cell Transplant 2003: 12: 787797. 92. Howell TH, Fiorellini JP, Paquette DW, Offenbacher S, Giannobile WV, Lynch SE. A phase I/II clinical trial to evaluate a combination of recombinant human plateletderived growth factor-BB and recombinant human insulinlike growth factor-I in patients with periodontal disease. J Periodontol 1997: 68: 11861193. 93. Huang KK, Shen C, Chiang CY, Hsieh YD, Fu EJ. Effects of bone morphogenetic protein-6 on periodontal wound healing in a fenestration defect of rats. J Periodontal Res 2005: 40: 110. 94. Igarashi R, Sahara T, Shimizu-Ishiura M, Sasaki T. Porcine enamel matrix derivative enhances the formation of reparative dentine and dentine bridges during wound healing of amputated rat molars. J Electron Microsc 2003: 52: 227236. 95. Inoue M, LeGeros RZ, Hoffman C, Diamond K, Rosenberg PA, Craig RG. Effect of enamel matrix proteins on the phenotype expression of periodontal ligament cells cultured on dental materials. J Biomed Mater Res 2004: 69A: 172179. 96. Ishizaki NT, Matsumoto K, Kimura Y, Wang X, Yamashita A. Histopathological study of dental pulp tissue capped with enamel matrix derivative. J Endod 2003: 29: 176179. 97. Ivanovski S, Li H, Haase HR, Bartold PM. Expression of bone associated macromolecules by gingival and periodontal ligament broblasts. J Periodontal Res 2001: 36: 131141. 98. Iwata T, Morotome Y, Tanabe T, Fukae M, Ishikawa I, Oida S. Noggin blocks osteoinductive activity of porcine enamel extracts. J Dent Res 2002: 81: 387391. 99. Jepsen S, Eberhard J, Herrera D, Needleman I. A systematic review of guided tissue regeneration for periodontal furcation defects. What is the effect of guided tissue regeneration compared with surgical debridement in the treatment of furcation defects? J Clin Periodontol 2002: 29: 103116. 100. Jernvall J, Thesleff I. Reiterative signaling and patterning during mammalian tooth morphogenesis. Mech Dev 2000: 92: 1929. 101. Jiang J, Safavi KE, Spangberg LS, Zhu Q. Enamel matrix derivative prolongs primary osteoblast growth. J Endod 2001: 27: 110112. 102. Jiang J, Fouad AF, Safavi KE, Spangberg LS, Zhu Q. Effects of enamel matrix derivative on gene expression of primary osteoblasts. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001: 91: 95100. 103. Jin QM, Anusaksathien O, Webb SA, Rutherford RB, Giannobile WV. Gene therapy of bone morphogenetic protein for periodontal tissue engineering. J Periodontol 2003: 74: 202213. 104. Jin Q, Anusaksathien O, Webb SA, Printz MA, Giannobile WV. Engineering of tooth-supporting structures by delivery of PDGF gene therapy vectors. Mol Ther 2004: 9: 519526. 105. Kagayama M, Sasano Y, Zhu JX, Hirata M, Mizohuchi I, Kamakura S. Epithelial rest colocalize with cementoblasts forming acellular cementum but not with cementoblasts forming cellular cementum. Acta Anat 1998: 163: 19. 106. Kalajzic I, Braut A, Guo D, Jiang X, Kronenberg MS, Mina M, Harris MA, Harris SE, Rowe DW. Dentin matrix protein 1 expression during osteoblastic differentiation, generation of an osteocyte GFP-transgene. Bone 2004: 35: 7482. 107. Kalpidis CD, Ruben MP. Treatment of intrabony periodontal defects with enamel matrix derivative: a literature review. J Periodontol 2002: 73: 13601376. 108. Kaneko H, Hashimoto S, Enokiya Y, Ogiuchi H, Shimono M. Cell proliferation and death of Hertwigs epithelial root sheath in the rat. Cell Tissue Res 1999: 298: 95103. 109. Karatzas S, Zavras A, Greenspan D, Amar S. Histologic observations of periodontal wound healing after treatment with PerioGlas in nonhuman primates. Int J Periodontics Restorative Dent 1999: 19: 489499. 110. Karlan MS, Hench LL, Madden M, Ogino M. A bonebonding bioactive material implant in the head and neck: bioglass. Surg Forum 1978: 29: 575577. 111. Kawaguchi H, Hirachi A, Hasegawa N, Iwata T, Hamaguchi H, Shiba H, Takata T, Kato Y, Kurihara H. Enhancement of periodontal tissue regeneration by transplantation of bone marrow mesenchymal stem cells. J Periodontol 2004: 75: 12811287. 112. Kawase T, Okuda K, Yoshie H, Burns DM. Cytostatic action of enamel matrix derivative (EMDOGAIN) on human oral squamous cell carcinoma-derived SCC25 epithelial cells. J Periodontal Res 2000: 35: 291300. 113. Kawase T, Okuda K, Momose M, Kato Y, Yoshie H, Burns DM. Enamel matrix derivative (EMDOGAIN) rapidly stimulates phosphorylation of the MAP kinase family and nuclear accumulation of smad2 in both oral epithelial and broblastic human cells. J Periodontal Res 2001: 36: 367 376. 114. Kawase T, Okuda K, Yoshie H, Burns DM. Anti-TGF-beta antibody blocks enamel matrix derivative-induced upregulation of p21WAF1/cip1 and prevents its inhibition of human oral epithelial cell proliferation. J Periodontal Res 2002: 37: 255262. 115. Keila S, Nemcovsky CE, Moses O, Artzi Z, Weinreb M. In vitro Effects of Enamel Matrix Proteins on Rat Bone Marrow Cells and Gingival Fibroblasts. J Dent Res 2004: 83: 134138. 116. King GN. New regenerative technologies: rationale and potential for periodontal regeneration: 2. Growth factors. Dent Update 2001: 28: 6065. 117. King GN. New regenerative technologies: rationale and potential for periodontal regeneration: 1. New advances in established regenerative strategies. Dent Update 2001: 28: 712. 118. King GN, Cochran DL. Factors that modulate the effects of bone morphogenetic protein-induced periodontal regeneration: a critical review. J Periodontol 2002: 73: 925936. 119. King GN, Hughes FJ. Bone morphogenetic protein-2 stimulates cell recruitment and cementogenesis during early wound healing. J Clin Periodontol 2001: 28: 465475. 120. King GN, King N, Cruchley AT, Wozney JM, Hughes FJ. Recombinant human bone morphogenetic protein-2 promotes wound healing in rat periodontal fenestration defects. J Dent Res 1997: 76: 14601470.

212

Regeneration of periodontal tissues: cementogenesis revisited


121. King GN, King N, Hughes FJ. Effect of two delivery systems for recombinant human bone morphogenetic protein-2 on periodontal regeneration in vivo. J Periodontal Res 1998: 33: 226236. 122. Kittel PW, Sampson WJ. RME-induced root resorption and repair: a computerised 3-D reconstruction. Aust Orthod J 1994: 13: 144151. 123. Kobayashi M, Takiguchi T, Suzuki R, Yamaguchi A, Deguchi K, Shionome M, Miyazawa Y, Nishihara T, Nagumo M, Hasegawa K. Recombinant human bone morphogenetic protein-2 stimulates osteoblastic differentiation in cells isolated from human periodontal ligament. J Dent Res 1999: 78: 16241633. 124. Koike H, Uzawa K, Grzesik WJ, Seki N, Endo Y, Kasamatsu A, Yamauchi M, Tanzawa H. GLUT1 is highly expressed in cementoblasts but not in osteoblasts. Connect Tissue Res 2005: 46: 117124. 125. Kostopoulos L, Karring T. Susceptibility of GTR-regenerated periodontal attachment to ligature-induced periodontitis. J Clin Periodontol 2004: 31: 336340. 126. Lambrichts I, Creemers J, Van Steenberghe D. Periodontal neural endings intimately relate to epithelial rests of Malassez in humans. A light and electron microscope study. J Anat 1993: 182: 153162. 127. Lamster IB. Current concepts and future trends for periodontal disease and periodontal therapy, Part 2: Classication, diagnosis, and nonsurgical and surgical therapy. Dent Today 2001: 20: 8691. 128. Lamster IB, Karabin SD. Periodontal disease activity. Curr Opin Dent 1992;2: 3952. 129. Lang H, Schuler N, Nolden R. Attachment formation following replantation of cultured cells into periodontal defects a study in minipigs. J Dent Res 1998: 77: 393405. 130. Lekic PC, Rajshankar D, Chen H, Tenenbaum H, McCulloch CA. Transplantation of labeled periodontal ligament cells promotes regeneration of alveolar bone. Anat Rec 2001: 262: 193202. 131. Lekic PC, Nayak BN, Al-Sanea R, Tenenbaum H, Ganss B, McCulloch C. Cell transplantation in wounded mixed connective tissues. Anat Rec A Discov Mol Cell Evol Biol 2005: 287: 12561263. 132. Lezot F, Davideau JL, Thomas B, Sharpe P, Forest N, Berdal A. Epithelial Dlx-2 homeogene expression and cementogenesis. J Histochem Cytochem 2000: 48: 277284. 133. Lindskog S, Hammarstrom L. Formation of intermediate cementum III. 3H-tryptophan and 3H-proline uptake into the epithelial root sheath of Hertwig in vitro. J Craniofac Genet Dev Biol 1982: 2: 171177. 134. Lindskog S, Blomlof L, Hammarstrom L. Evidence for a role of odontogenic epithelium in maintaining the periodontal space. J Clin Periodontol 1988: 15: 371373. 135. Listgarten MA. Similarity of epithelial relationships in the gingiva of rat and man. J Periodontol 1975: 46: 677680. 136. Lubbock MJ, Harrison VT, Lumsden AG, Palmer RM. Development and cell fate in interspecic (Mus musculus/ Mus caroli) intraocular transplants of mouse molar toothgerm tissues detected by in situ hybridization. Arch Oral Biol 1996: 41: 7784. 137. Lukinmaa PL, Mackie EJ, Thesleff I. Immunohistochemical localization of the matrix glycoprotein-tenascin and the ED-sequence form of cellular bronectin. J Dent Res 1991: 70: 1926. 138. Lynch SE, Ruiz de Castilla G, Williams RC, Kiritsy CP, Howell TH, Reddy MS, Antoniades HN. The effects of short-term application of a combination of platelet-derived and insulin-like growth factors on periodontal wound healing. J Periodontol 1991: 62: 458467. 139. Lyngstadaas SP, Lundberg E, Ekdahl H, Andersson C, Gestrelius S. Autocrine growth factors in human periodontal ligament cells cultured on enamel matrix derivative. J Clin Periodontol 2001: 28: 181188. 140. MacNeil RL, Thomas HF. Development of the murine periodontium. I. role of basement membrane in formation of a mineralized tissue on the developing root dentin surface. J Periodontol 1993: 64: 95102. 141. MacNeil RL, Thomas HF. Development of the murine periodontium. II. Role of the epithelial root sheath in formation of the periodontal attachment. J Periodontol 1993: 64: 285291. 142. Macneil RL, Berry J, Strayhorn C, Somerman MJ. Expression of bone sialoprotein mRNA by cells lining the mouse tooth root during cementogenesis. Arch Oral Biol 1996: 41: 827835. 143. Madan AK, Kramer B. Immunolocalization of broblast growth factor-2 (FGF-2) in the developing root and supporting structures of the murine tooth. J Mol Histol 2005: 36: 171178. 144. Mariotti A. The extracellular matrix of the periodontium: dynamic and interactive tissues. Periodontol 2000 1993: 3: 3963. 145. Mariotti A Efcacy of chemical root surface modiers in the treatment of periodontal disease. A systematic review. Ann Periodontol 2003: 8: 205226. 146. Matsuda N, Lin WL, Kumar NM, Cho MI, Genco RJ. Mitogenic, chemotactic, and synthetic responses of rat periodontal ligament broblastic cells to polypeptide growth factors in vitro. J Periodontol 1992: 63: 515525. 147. Matsuura M, Herr Y, Han KY, Lin WL, Genco RJ, Cho MI. Immunohistochemical expression of extracellular matrix components of normal and healing periodontal tissues in the beagle dog. J Periodontol 1995: 66: 579593. 148. Maycock J, Wood SR, Brookes SJ, Shore RC, Robinson C, Kirkham J. Characterization of a porcine amelogenin preparation, EMDOGAIN, a biological treatment for periodontal disease. Connect Tissue Res 2002: 43: 472476. 149. McAllister B, Narayanan AS, Miki Y, Page RC. Isolation of a broblast attachment protein from cementum. J Periodontal Res 1990: 25: 99105. 150. McCulloch CA Origins and functions of cells essential for periodontal repair: the role of broblasts in tissue homeostasis. Oral Dis 1995: 1: 271278. 151. McCulloch CA, Lekic P, McKee MD. Role of physical forces in regulating the form and function of the periodontal ligament. Periodontol 2000 2000: 24: 5672. 152. Melcher AH On the repair potential of periodontal tissues. J Periodontol 1976: 47: 256260. 153. Melcher AH. Cells of periodontium: their role in the healing of wounds. Ann R Coll Surg Engl 1985: 67: 130131. 154. Mellonig JT Enamel matrix derivative for periodontal reconstructive surgery: technique and clinical and histologic case report. Int J Periodontics Restorative Dent 1999: 19: 819. 155. Merrilees MJ, Sodek J, Aubin JE. Effects of cells of epithelial rests of Malassez and endothelial cells on synthesis of

213

Zeichner-David
glycosaminoglycans by periodontal ligament broblasts in vitro. Dev Biol 1983: 97: 146153. Metzger Z, Weinstock B, Dotan M, Narayanan AS, Pitaru S. Differential chemotactic effect of cementum attachment protein on periodontal cells. J Periodontal Res 1998: 33: 126129. Miki Y, Narayanan AS, Page RC. Mitogenic activity of cementum components to gingival broblasts. J Dent Res 1987: 66: 13991403. Miletich I, Sharpe PT. Neural crest contribution to mammalian tooth formation. Birth Defects Res C Embryo Today 2004: 72: 200212. Miller N, Penaud J, Foliguet B, Membre H, Ambrosini P, Plombas M. Resorption rates of 2 commercially available bioresorbable membranes. A histomorphometric study in a rabbit model. J Clin Periodontol 1996: 23: 10511059. Mirastschijski U, Konrad D, Lundberg E, Lyngstadaas SP, Jorgensen LN, Agren MS. Effects of a topical enamel matrix derivative on skin wound healing. Wound Repair Regen 2004: 12: 100108. Mizutani S, Tsuboi T, Tazoe M, Koshihara Y, Goto S, Togari A. Involvement of FGF-2 in the action of Emdogain on normal human osteoblastic activity. Oral Dis 2003: 9: 210 217. Morsczeck C, Gotz W, Schierholz J, Zeilhofer F, Kuhn U, Mohl C, Sippel C, Hoffmann KH. Isolation of precursor cells (PCs) from human dental follicle of wisdom teeth. Matrix Biol 2005: 24: 155165. Murphy KG, Gunsolley JC. Guided tissue regeneration for the treatment of periodontal intrabony and furcation defects. A systematic review. Ann Periodontol 2003: 8: 266 302. Murphy WL, Mooney DJ. Controlled delivery of inductive proteins, plasmid DNA and cells from tissue engineering matrices. J Periodontal Res 1999: 34: 413419. Nabers CL, Pfeifer JS, Raust GT Jr, Ross SJ. What is the place of bone grafts in periodontal therapy? Periodontal Abstr 1967: 5: 149153. Nagano T, Iwata T, Ogata Y, Tanabe T, Gomi K, Fukae M, Arai T, Oida S. Effect of heat treatment on bioactivities of enamel matrix derivatives in human periodontal ligament(HPDL) cells. J Periodontal Res 2004: 39: 249256. Nakae H, Narayanan S, Raines E, Page RC. Isolation and partial characterization of mitogenic factors from cementum. Biochemistry 1991: 30: 70477052. Nakamura Y, Hammarstrom L, Lundberg E, Ekdahl H, Matsumoto K, Gestrelius S, Lyngstadaas SP. Enamel matrix derivative promotes reparative processes in the dental pulp. Adv Dent Res 2001: 15: 105107. Nakamura Y, Hammarstrom L, Matsumoto K, Lyngstadaas SP. The induction of reparative dentine by enamel proteins. Int Endod J 2002: 35: 407417. Nakashima M, Reddi AH. The application of bone morphogenetic proteins to dental tissue engineering. Nat Biotechnol 2003: 21: 10251032. Nevins M, Camelo M, Nevins ML, Schenk RK, Lynch SE. Periodontal regeneration in humans using recombinant human platelet-derived growth factor-BB (rhPDGF-BB) and allogenic bone. J Periodontol 2003: 74: 12821292. Newman SA, Coscia SA, Jotwani R, Iacono VJ, Cutler CW. Effects of enamel matrix derivative on Porphyromonas gingivalis. J Periodontol 2003: 74: 11911195. 173. Nishimura K, Hayahi M, Matsuda K, Shigeyama Y, Yamasaki A, Yamaoka A. The chemoattractive potency of periodontal ligament, cementum and dentin for human gingival broblasts. J Periodontal Res 1989: 24: 146148. 174. Nyman S, Gottlow J, Karring T, Lindhe J. The regenerative potential of the periodontal ligament. An experimental study in the monkey. J Clin Periodontol 1982: 9: 257265. 175. Oates TW, Rouse CA, Cochran DL. Mitogenic effects of growth factors on human periodontal ligament cells in vitro. J Periodontol 1993: 64: 142148. 176. Ohshima M, Nishiyama T, Tokunaga K, Sato S, Maeno M, Otsuka K. Proles of cytokine expression in radicular cystlining epithelium examined by RT-PCR. J Oral Sci 2000: 42: 239246. 177. Ohyama M, Suzuki N, Yamaguchi Y, Maeno M, Otsuka K, Ito K. Effect of enamel matrix derivative on the differentiation of C2C12 cells. J Periodontol 2002: 73: 543550. 178. Okubo K, Kobayashi M, Takiguchi T, Takada T, Ohazama A, Okamatsu Y, Hasegawa K. Participation of endogenous IGF-I and TGF-beta 1 with enamel matrix derivative-stimulated cell growth in human periodontal ligament cells. J Periodontal Res 2003: 38: 19. 179. Okuda K, Momose M, Miyazaki A, Murata M, Yokoyama S, Yonezawa Y, Wolff LF, Yoshie H. Enamel matrix derivative in the treatment of human intrabony osseous defects. J Periodontol 2000: 71: 18211828. 180. Okuda K, Kawase T, Momose M, Murata M, Saito Y, Suzuki H, Wolff LF, Yoshie H. Platelet-rich plasma contains high levels of platelet-derived growth factor and transforming growth factor-beta and modulates the proliferation of periodontally related cells in vitro. J Periodontol 2003: 74: 849857. 181. Orban B. The epithelial network in the periodontal membrane. J Am Dent Assoc 1952: 44: 632635. 182. Owens PDA. Ultrastructure of Hertwigs epithelial root sheath during early root development in premolar teeth in dogs. Arch Oral Biol 1978: 23: 91104. 183. Owens PDA. A light and electron microscopic study of early stages of root surface formation in molar teeth in the rat. Arch oral Biol 1980: 24: 901907. 184. Palioto DB, Coletta RD, Graner E, Joly JC, de Lima AF. The inuence of enamel matrix derivative associated with insulin-like growth factor-I on periodontal ligament broblasts. J Periodontol 2004: 75: 498504. 185. Palmer RM, Lubbock MJ. The soft connective tissues of the gingiva and periodontal ligament: are they unique? Oral Dis 1995: 1: 230237. 186. Palmer RM, Lumsden AG. Development of periodontal ligament and alveolar bone in homografted recombinations of enamel organs and papillary, pulpal, and follicular mesenchyme in the mouse. Arch Oral Biol 1987: 32: 281 289. 187. Parashis A, Tsiklakis K. Clinical and radiographic ndings following application of enamel matrix derivative in the treatment of intrabony defects. A series of case reports. J Clin Periodontol 2000: 27: 705713. 188. Park JB, Matsuura M, Han KY, Norderyd O, Lin WL, Genco RJ. Periodontal regeneration in class III furcation defects in beagle dogs using guided tissue regenerative therapy with platelet-derived growth factor. J Periodontol 1995: 66: 462 477.

156.

157.

158.

159.

160.

161.

162.

163.

164.

165.

166.

167.

168.

169.

170.

171.

172.

214

Regeneration of periodontal tissues: cementogenesis revisited


189. Parodi R, Liuzzo G, Patrucco P, Brunel G, Santarelli GA, Birardi V, Gaspretto B. Use of Emdogain in the treatment of deep intrabony defects: 12-month clinical results. Histologic and radiographic evaluation. Int J Periodontics Restorative Dent 2000: 6: 584595. 190. Parodi R, Santarelli GA, Gasparetto B. Treatment of intrabony pockets with Emdogain: results at 36 months. Int J Periodontics Restorative Dent 2004: 24: 5763. 191. Paynter KJ, Pudy G. A study of the structure, chemical nature, and development of cementum in the rat. Anat Rec 1958: 131: 233251. 192. Peters H, Balling R. Teeth, where and how to make them. Trends Genet 1999: 15: 5964. 193. Phipps RP, Borrello MA, Blieden TMJ. Fibroblast heterogeneity in the periodontium and other tissues. J Periodontal Res 1997: 32: 159165. 194. Pihlstrom BL, Michalowicz BS, Johnson NW. Periodontal diseases. Lancet 2005: 366: 18091820. 195. Pitaru S, McCulloch CA, Narayanan AS. Cellular origins and differentiation control mechanisms during periodontal development and wound healing. J Periodontal Res 1994: 29: 8194. 196. Pitaru S, Narayanan SA, Olsen S, Avion N, Hekmati H, Alt I, Metzger Z. Specic cementum attachment protein enhances selectively the attachment and migration of periodontal cells to root surfaces. J Periodontal Res 1995: 30: 360368. 197. Plemons JM, Dill RE, Rees TD, Dyer BJ, Ng MC, Iacopino AM. PDGF-B producing cells and PDGF-B gene expression in normal gingival and cyclosporine A-induced gingival overgrowth. J Periodontol 1996: 67: 264270. 198. Plikus MV, Zeichner-David M, Mayer JA, Reyna J, Bringas P, Thewissen JG, Snead ML, Chai Y, Chuong CM. Morphoregulation of teeth: modulating the number, size, shape and differentiation by tuning Bmp activity. Evol Dev 2005: 7: 440457. 199. Price JA, Wright JT, Kula K, Bowden DW, Hart TC. A common DLX3 gene mutation is responsible for trichodento-osseous syndrome in Virginia and North Carolina families. J Med Genet 1998: 35: 825828. 200. Rasperini G, Ricci G, Silvestri M. Surgical technique for treatment of infrabony defects with enamel matrix derivative (Emdogain): 3 case reports. Int J Periodontics Restorative Dent 1999: 19: 578587. 201. Reichert T, Storkel S, Becker K, Fisher LW. The role of osteonectin in human tooth development: an immunohistological study. Calc Tissue Int 1992: 50: 468472. 202. Reynolds MA, Aichelmann-Reidy ME, Branch-Mays GL, Gunsolley JC. The efcacy of bone replacement grafts in the treatment of periodontal osseous defects. A systematic review. Ann Periodontol 2003: 8: 227265. 203. Rincon JC, Haase HR, Bartold PM. Effect of Emdogain on human periodontal broblasts in an in vitro wound-healing model. J Periodontal Res 2003: 38: 290295. 204. Rincon JC, Xiao Y, Young WG, Bartold PM. Enhanced proliferation, attachment and osteopontin expression by porcine periodontal cells exposed to Emdogain. Arch Oral Biol 2005: 50: 10471054. 205. Ripamonti U, Reddi AH. Tissue engineering, morphogenesis, and regeneration of the periodontal tissues by bone morphogenetic proteins. Crit Rev Oral Biol Med 1997: 8: 154163. 206. Ripamonti U, Petit JC, Lemmer J, Austin JC. Regeneration of the connective tissue attachment on surgically exposed roots using brin-bronectin adhesive system. An experimental study on the baboon (Papio ursinus). J Periodontal Res 1987: 22: 320326. 207. Ripamonti U, Crooks J, Petit JC, Rueger DC. Periodontal tissue regeneration by combined applications of recombinant human osteogenic protein-1 and bone morphogenetic protein-2. A pilot study in Chacma baboons (Papio ursinus). Eur J Oral Sci 2001: 109: 241248. 208. Robey PG, Bianco P, Termine JD. The cellular biology and molecular biochemistry of bone formation. In: Coe FI, Favuus MJ, editors. Disorders of Bone and Mineral Metabolism. New York: Raven Press, 1992: 241263. 209. Rose LF, Rosenberg E. Bone grafts and growth and differentiation factors for regenerative therapy: a review. Pract Proced Aesthet Dent 2001: 13: 725734. 210. Rutherford RB, Niekrash CE, Kennedy JE, Charette MF. Platelet-derived and insulin-like growth factors stimulate regeneration of periodontal attachment in monkeys. J Periodontal Res 1992: 27: 285290. 211. Rutherford RB, Ryan ME, Kennedy JE, Tucker MM, Charette MF. Platelet-derived growth factor and dexamethasone combined with collagen matrix induce regeneration of the periodontium in monkeys. J Clin Periodontol 1993: 20: 537544. 212. Saffar JL, Lasfargues JJ, Cherruau M. Alveolar bone and the alveolar process: the socket that is never stable. Periodontol 2000 1997: 13: 7690. 213. Sato Y, Kikuchi M, Ohata N, Tamura M, Kuboki Y. Enhanced cementum formation in experimentally induced cementum defects of the root surface with the application of recombinant basic broblast growth factor in collagen gel in vivo. J Periodontol 2004: 75: 243248. 214. Schroeder HE, Listgarten MA. The gingival tissues: the architecture of periodontal protection. Periodontol 2000 1997: 13: 91120. 215. Schwartz Z, Carnes DL Jr, Pulliam R, Lohmann CH, Sylvia VL, Liu Y, Dean DD, Cochran DL, Boyan BD. Porcine fetal enamel matrix derivative stimulates proliferation but not differentiation of pre-osteoblastic 2T9 cells, inhibits proliferation and stimulates differentiation of osteoblast-like MG63 cells, and increases proliferation and differentiation of normal human osteoblast NHOst cells. J Periodontol 2000: 71: 12871296. 216. Sculean A, Donos N, Blaes A, Lauermann M, Reich E, Brecx M. Comparison of enamel matrix proteins and bioabsorbable membranes in the treatment of intrabony periodontal defects. A split-mouth study. J Periodontol 1999: 70: 255262. 217. Sculean A, Chiantella GC, Windisch P, Donos N. Clinical and histologic evaluation of human intrabony defects treated with an enamel matrix protein derivative (Emdogain). Int J Periodontics Restorative Dent 2000: 20: 374381. 218. Sculean A, Donos N, Brecx M, Reich E, Karring T. Treatment of intrabony defects with guided tissue regeneration and enamel-matrix-proteins. An experimental study in monkeys. J Clin Periodontol 2000: 27: 466472. 219. Sculean A, Donos N, Brecx M, Karring T, Reich E. Healing of fenestration-type defects following treatment with guided tissue regeneration or enamel matrix proteins. An experimental study in monkeys. Clin Oral Investig 2000: 4: 5056.

215

Zeichner-David
220. Sculean A, Auschill TM, Donos N, Brecx M, Arweiler NB. Effect of an enamel matrix protein derivative (Emdogain) on ex vivo dental plaque vitality. J Clin Periodontol 2001: 28: 10741078. 221. Sculean A, Windisch P, Keglevich T, Gera I. Clinical and histologic evaluation of an enamel matrix protein derivative combined with a bioactive glass for the treatment of intrabony periodontal defects in humans. Int J Periodontics Restorative Dent 2005: 25: 139147. 222. Selvig KA. Electron microscopy of Hertwigs epithelial sheath and of early dentin and cementum formation in the mouse incisor. Acta Odontol Scand 1963: 21: 175186. 223. Sena K, Morotome Y, Baba O, Terashima T, Takano Y, Ishikawa I. Gene expression of growth differentiation factors in the developing periodontium of rat molars. J Dent Res 2003: 82: 166171. 224. Seo BM, Miura M, Gronthos S, Bartold PM, Batouli S, Brahim J, Young M, Robey PG, Wang CY, Shi S. Investigation of multipotent postnatal stem cells from human periodontal ligament. Lancet 2004: 364: 149155. 225. Seo BM, Miura M, Sonoyama W, Coppe C, Stanyon R, Shi S. Recovery of stem cells from cryopreserved periodontal ligament. J Dent Res 2005: 84: 907912. 226. Shear M, Pindborg JJ. Microscopic features of the lateral periodontal cyst. Scand J Dent Res 1975: 83: 103110. 227. Shimizu E, Nakajima Y, Kato N, Nakayama Y, Saito R, Samoto H, Ogata Y. Regulation of rat bone sialoprotein gene transcription by enamel matrix derivative. J Periodontol 2004: 75: 260267. 228. Shimizu E, Saito R, Nakayama Y, Nakajima Y, Kato N, Takai H, Kim DS, Arai M, Simmer J, Ogata Y. Amelogenin stimulates bone sialoprotein (BSP) expression through broblast growth factor 2 response element and transforming growth factor-beta1 activation element in the promoter of the BSP gene. J Periodontol 2005: 76: 14821489. 229. Shimizu-Ishiura M, Tanaka S, Lee WS, Debari K, Sasaki T. Effects of enamel matrix derivative to titanium implantation in rat femurs. J Biomed Mater Res 2002: 60: 269276. 230. Shroff B, Kashner JE, Keyser JD, Hebert C, Norris K Epidermal growth factor and epidermal growth factor-receptor expression in the mouse dental follicle during tooth eruption. Arch Oral Biol 1996: 41: 613617. 231. Silvestri M, Rasperini G, Euwe E. Enamel matrix derivative in treatment of infrabony defects. Pract Periodontics Aesthet Dent 1999: 11: 615616. 232. Slavkin HC. Towards a cellular and molecular understanding of periodontics: cementogenesis revisited. J Periodontol 1976: 47: 249255. 233. Slavkin HC, Boyd A. Cementum: an epithelial secretory product? J Dent Res 1974: 53: 157. 234. Slavkin HC, Bringas P, Bessem C, Santos V, Nakamura M, Hsu M, Snead ML, Zeichner-David M, Fincham AG. Hertwigs epithelial root sheath differentiation and initial cementum and bone formation during long-term organ culture of mouse mandibular rst molars using serumless, chemically-dened medium. J Periodontal Res 1988: 23: 2840. 235. Slavkin HC, Bessem C, Fincham AG, Bringas P, Santos V, Snead ML, Zeichner-David M. Human and mouse cementum proteins immunologically related to enamel proteins. Biochim Biophys Acta 1989: 991: 1218. 236. Somerman MJ, Perez-Mera M, Merkhofer RM, Foster RA. In vitro evaluation of extracts of mineralized tissues for their application in attachment of brous tissue. J Periodontol 1987: 58: 349351. 237. Spahr A, Lyngstadaas SP, Boeckh C, Andersson C, Podbielski A, Haller B. Effect of the enamel matrix derivative Emdogain on the growth of periodontal pathogens in vitro. J Clin Periodontol 2002: 29: 6272. 238. Spouge JD. A new look at the rests of Malassez: a review of their embryological origin, anatomy, and possible role in periodontal health and disease. J Periodontol 1980: 51: 437444. 239. Steele-Perkins G, Butz KG, Lyons GE, Zeichner-David M, Kim HJ, Cho MI, Gronostajski RM. Essential role for NFI-C/ CTF transcription-replication factor in tooth root development. Mol Cell Biol 2003: 23: 10751084. 240. Sykaras N, Opperman LA. Bone morphogenetic proteins (BMPs): how do they function and what can they offer the clinician? J Oral Sci 2003: 45: 5773. 241. Talic NF, Evans CA, Daniel JC, Zaki AE. Proliferation of epithelial rests of Malassez during experimental tooth movement. Am J Orthod Dentofacial Orthop 2003: 123: 527533. 242. Tatemoto Y, Okada Y, Mori M. Squamous odontogenic tumor: immunohistochemical identication of keratins. Oral Surg Oral Med Oral Pathol 1989: 67: 6367. 243. Ten Cate AR. A ne structural study of coronal and root dentinogenesis in the mouse. Observations of the so called von korff bers and their contribution to mantle dentine. J Anat 1978: 125: 183197. 244. Ten Cate AR. The role of epithelium in the development, structure and function of the tissues of tooth support. Oral Dis 1996: 2: 5562. 245. Ten Cate AR, Mills C. The development of the periodontium: the origin of alveolar bone. Anat Rec 1972: 173: 6978. 246. Tenorio D, Cruchley A, Hughes FJ. Immunocytochemical investigation of the rat cementoblast phenotype. J Periodontal Res 1993: 28: 411419. 247. Terranova VP. Periodontal and bone regeneration factor, materials and methods. International patent # WO 90/ 100017. 1990. 248. Terranova VP, Wikesjo UM. Extracellular matrices and polypeptide growth factors as mediators of functions of cells of the periodontium. J Periodontol 1987: 58: 371380. 249. Thesleff I. Developmental biology and building a tooth. Quintessence Int 2003: 34: 613620. 250. Thomadakis G, Ramoshebi LN, Crooks J, Rueger DC, Ripamonti U. Immunolocalization of Bone Morphogenetic Protein-2 and -3 and Osteogenic Protein-1 during murine tooth root morphogenesis and in other craniofacial structures. Eur J Oral Sci 1999: 107: 368377. 251. Thomas HF. Root formation. Int J Dev Biol 1995: 39: 231237. 252. Thomas HF, Kollar EJ. Differentiation of odontoblasts in grafted recombinants of murine epithelial root sheath and dental mesenchyme. Arch Oral Biol 1989: 34: 2735. 253. Thomas BL, Tucker AS, Qui M, Ferguson CA, Hardcastle Z, Rubenstein JL, Sharpe P. Role of Dlx-1 and Dlx-2 genes in patterning of the murine dentition. Development 1997: 124: 48114818. 254. Tokiyasu Y, Takata T, Saygin E, Somerman M. Enamel factors regulate expression of genes associated with cementoblasts. J Periodontol 2000: 71: 18291839.

216

Regeneration of periodontal tissues: cementogenesis revisited


255. Toyosawa S, Okabayashi K, Komori T, Ijuhin N. mRNA expression and protein localization of dentin matrix protein 1 during dental root formation. Bone. 2004: 34: 124 133. 256. Van der Pauw MT, Van den Bos T, Everts V, Beertsen W. Enamel matrix-derived protein stimulates attachment of periodontal ligament broblasts and enhances alkaline phosphatase activity and transforming growth factor beta1 release of periodontal ligament and gingival broblasts. J Periodontol 2000: 71: 3143. 257. Venezia E, Goldstein M, Boyan BD, Schwartz Z. The use of enamel matrix derivative in the treatment of periodontal defects: a literature review and meta-analysis. Crit Rev Oral Biol Med 2004: 15: 382402. 258. Viswanathan HL, Berry JE, Foster BL, Gibson CW, Li Y, Kulkarni AB, Snead ML, Somerman MJ. Amelogenin: a potential regulator of cementum-associated genes. J Periodontol 2003: 74: 14231431. 259. Wallace JA, Vergona K. Epithelial rests function in replantation: is splinting necessary in replantation? Oral Surg Oral Med Oral Pathol 1990: 70: 644649. 260. Wang HL, Greenwell H, Fiorellini J, Giannobile W, Offenbacher S, Salkin L, Townsend C, Sheridan P, Genco RJ. Research, Science and Therapy Committee. Periodontal regeneration. J Periodontol 2005: 76: 16011622. 261. Wesselink PR, Beertsen W. The prevalence and distribution of Malassez in the mouse molar and their possible role in repair and maintenance of the periodontal ligament. Arch Oral Biol 1993: 88: 399403. 262. Wikesjo UME, Claffey N, Christersson LA, Franzetti LC, Genco RJ, Terranova VP. Repair of periodontal furcation defects in beagle dogs following reconstructive surgery including root surface de-mineralization with tetracycline hydrochloride and topical bronectin application. J Clin Periodontol 1988: 15: 7380. 263. Wu D-Y, Ikezawa K, Parker T, Saito M, Narayanan A-S. Characterization of a collagenous cementum-derived attachment. J Bone Mineral Res 1996: 11: 686692. 264. Yamamoto H, Cho SW, Kim EJ, Kim JY, Fujiwara N, Jung HS. Developmental properties of the Hertwigs epithelial root sheath in mice. J Dent Res 2004: 83: 688692. 265. Yamamoto T, Domon T, Takahashi S, Arambawatta AK, Wakita M. Immunolocation of proteoglycans and bonerelated noncollagenous glycoproteins in developing acellular cementum of rat molars. Cell Tissue Res 2004: 317: 299312. 266. Yamashiro T, Tummers M, Thesleff I. Expression of bone morphogenetic proteins and Msx genes during root formation. J Dent Res 2003: 82: 172176. 267. Yamaza T, Kido MA, Tanaka T, Hashimoto S, Shimono M, Ishikawa T, Enokiya Y, Muramatsu T, Matsuzaka K, Inoue T, Abiko Y. Biological characteristics of the junctional epithelium. J Electron Microsc 2003: 52: 627639. Yoneda S, Itoh D, Kuroda S, Kondo H, Umezawa A, Ohya K, Ohyama T, Kasugai S. The effects of enamel matrix derivative (EMD) on osteoblastic cells in culture and bone regeneration in a rat skull defect. J Periodontal Res 2003: 38: 333342. Yonemura K, Narayanan AS, Miki Y, Page RC, Okada H. Isolation and partial characterization of a growth factor from cementum. Bone Mineral Res 1992: 18: 187198. Young WG. Growth hormone and insulin-like growth factor-I in odontogenesis. Int J Dev Biol 1995: 39: 263272. Yuan K, Chen CL, Lin MT. Enamel matrix derivative exhibits angiogenic effect in vitro and in a murine model. J Clin Periodontol 2003: 30: 732738. Zeichner-David M. Is there more to enamel matrix proteins than biomineralization? Matrix Biol 2001: 20: 307316. Zeichner-David M, Su Z, Chen L, Zakartchenko V, Caton J, Bringas P. Effect of recombinant mouse amelogenin and ameloblastin on periodontal ligament cell adhesion and proliferation. EJOS (In press). Zeichner-David M, Diekwisch T, Fincham A, Lau E, MacDougall M, Moradian-Oldak J, Simmer J, Snead M, Slavkin HC. Control of ameloblast cell differentiation. Int J Develop Biol 1995: 39: 6992. Zeichner-David M, Oishi K, Su Z, Zakartchenko V, Chen LS, Arzate H, Bringas P Jr. Role of Hertwigs epithelial root sheath cells in tooth root development. Dev Dyn 2003: 228: 651663. Zernik JH, Nowroozi N, Liu YH, Maxson R. Development, maturation, and aging of the alveolar bone. New insights. Dent Clin North Am 1997: 41: 115. Zetterstrom O, Andersson C, Eriksson L, Fredriksson A, Friskopp J, Heden G, Jansson B, Lundgren T, Nilveus R, Olsson A, Renvert S, Salonen L, Sjostrom L, Winell A, Ostgren A, Gestrelius S. Clinical safety of enamel matrix derivative (EMDOGAIN) in the treatment of periodontal defects. J Clin Periodontol 1997: 24: 697704. Zhao M, Xiao G, Berry JE, Franceschi RT, Reddi A, Somerman MJ. Bone morphogenetic protein 2 induces dental follicle cells to differentiate toward a cementoblast/ osteoblast phenotype. J Bone Miner Res 2002: 17: 1441 1451. Zhao M, Berry JE, Somerman MJ. Bone morphogenetic protein-2 inhibits differentiation and mineralization of cementoblasts in vitro. J Dent Res 2003: 82: 2327. Zhao M, Jin Q, Berry JE, Nociti FH Jr, Giannobile WV, Somerman MJ. Cementoblast delivery for periodontal tissue engineering. J Periodontol 2004: 75: 154161.

268.

269.

270. 271.

272. 273.

274.

275.

276.

277.

278.

279.

280.

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