Chapter #61

Hisham AlShorman
Aya AlHelo & Esraa Jaradat
************

6&7
Reconstructive techniques
* Subdivided into two major types: 1) nonbone graftassociated new attachment
2) bone graftassociated new attachment.
*These include careful case selection and complete removal of all irritants on the root surface.
*can be done in some cases as a closed procedure, in the great majority of cases it should be done after exposure of the
area with a flap.
*Trauma from occlusion, may impair post treatment healing of the supporting periodontal tissues, Occlusal adjustment
is therefore indicated.
*Systemic antibiotics are generally used after reconstructive periodontal therapy.

NonBone GraftAssociated Procedures

- Attained without the use of bone grafts in meticulously treated three-wall defects (intrabony defects) and in
periodontal and endodontic abscesses.
-New attachment is more likely to occur when the destructive process has occurred rapidly such as after treatment of
pockets complicated by acute periodontal abscesses and after treatment of acute necrotizing ulcerative lesions.
Rationale and techniques that must be considered for a successful outcome in periodontal bone regeneration:
1- Removal of Junctional and Pocket Epithelium.
Presence of junctional and pocket epithelium has been perceived as a barrier to successful therapy because its interferes
with the direct apposition of connective tissue and cementum, limiting the height to which periodontal fibers can insert
to the cementum.

Several methods have been recommended to remove the junctional

and pocket epithelium these include :

A- Curettage. Results of removal of the epithelium . vary from complete removal to persistence of as much as 50%. Therefore it is
not a reliable procedure. Ultrasonic methods, lasers, and rotary abrasive stones have also been used, but their effects cannot be
controlled because of the clinicians lack of vision and tactile sense when using these methods
B-Chemical Agents. Usually in conjunction with curettage. The drugs used sodium sulfide, phenol camphor, Antiformin, and
sodium hypochlorite. The effect of these agents is not limited to the epithelium, and their depth of penetration cannot be
controlled.
C-Surgical Techniques. Recommended to eliminate the pocket and junctional epithelium. The excisional new attachment
procedure consists of an internal bevel incision performed with a surgical knife, followed by removal of the excised tissue. No
attempt is made to elevate a flap. After careful scaling and root planing, interproximal sutures are used to close the wound
* Glickman and Prichard have advocated performing a gingivectomy to the crest of the alveolar bone and debriding the
defect. Excellent results have been obtained with this technique in uncontrolled human studies.
* The modified Widman flap is similar to the excisional new attachment procedure but is followed by elevation of a flap for
better exposure of the area. The internal bevel incision eliminates the pocket epithelium.

2- Prevention or Impeding the Epithelial Migration.

Elimination of the junctional and pocket epithelium may not be sufficient ,the epithelium from the excised margin may rapidly
proliferate to become interposed between the healing connective tissue and the cementum.
I. Root submergence : excluding the epithelium by amputating the crown of the tooth and covering the root with the flap,
This not only excludes the epithelium but also prevents microbial contamination of the wound during the reparative stages.
Successful repair of osseous lesions in the submerged environment was reported, but this method has little or no clinical
application.
II. Total removal of the interdental papilla covering the defect and its replacement with a free autogenous graft obtained
from the palate During healing, the graft epithelium necroses and is slowly replaced by proliferating epithelium from the
gingival surface. The graft simply delays the epithelium from proliferating into the healing area. Not widely used.
III. coronally displaced flaps: increase the distance between the epithelial wound edge and the healing area. This is particularly
suitable for the treatment of mandibular molar furcations and has been used mostly in conjunction with citric acid
treatment of the roots.
 3- Clot Stabilization, Wound Protection, and Space Creation.
Transference of this concept to periodontal therapy has been explored for treatment of periodontal and periimplant osseous defects
and for root coverage. The space can be created by using a titanium-reinforced expanded polytetrafluoroethylene (ePTFE)
membrane to prevent its collapse.

4- Guided tissue regeneration: The method for the prevention of epithelial migration along the cemental wall of the pocket
and maintaining space for clot stabilization (GTR) GTR consists of placing barriers of different types (membranes) to cover
the bone and periodontal ligament, temporarily separating them from the gingival epithelium and connective tissue.
Excluding the epithelium and the gingival connective tissue from the root surface during the postsurgical healing phase not
only prevents epithelial migration into the wound but also favors repopulation of the area by cells from the periodontal
ligament and the bone.

* Initial animal experiments using Millipore filters and Teflon membranes resulted in regeneration of cementum and alveolar
bone and a functional periodontal ligament. Histologic studies in humans provided evidence of periodontal reconstruction
in most cases, even with horizontal bone loss.
* The use of polytetrafluoroethylene (PTFE) membranes has been tested in controlled clinical studies in mandibular molar furcations
and has shown statistically significant decreases in pocket depths and improvement in attachment levels after 6 months, but bone
level measurements have been inconclusive. A study on maxillary molar furcations did not result in significant gain in attachment or
bone levels.
* The initial membranes developed were nonresorbable and required a second surgical procedure to remove them. This was
accomplished after the initial stages of healing, 3 to 6 weeks after the first intervention. The second procedure was a significant
obstacle in the utilization of the GTR technique, therefore the resorbable membranes were developed.

The ePTFE membrane (nonresorbable) can be obtained in different shapes and sizes to suit proximal spaces and facial/lingual
surfaces of furcations . The technique for its use is as follows
1. Raise a mucoperiosteal flap with vertical incisions, extending a minimum of two teeth anteriorly and one tooth distally to
the tooth being treated.
2. Debride the osseous defect and thoroughly plane the roots.
3. Trim the membrane to the approximate size of the area being treated. The apical border of the material should extend 3 to 4 mm
apical to the margin of the defect and laterally 2 to 3 mm beyond the defect. The occlusal border of the membrane should be placed
2 mm apical to the cementoenamel junction.
4. Suture the membrane tightly around the tooth with a sling suture.
5. Suture the flap back in its original position or slightly coronal to it, using independent sutures interdentally and in the vertical
incisions. The flap should cover the membrane completely.
6.Periodontal dressings is optional, the patient is placed on antibiotic therapy for 1 week.
*After 4 to 6 weeks, the margin of the membrane may become exposed. The membrane is removed carefully, minimizing trauma to
the underlying tissue.If it cannot be removed easily, the tissues are anesthetized, and the material is surgically removed using a small
flap.The results obtained with the GTR technique are enhanced when the technique is combined with grafts placed in the defects
 Biodegradable Membranes.
*Resorbable membranes has included trials and tests with numerous materials and collagens from different species such as
bovine, porcine, Cargile membrane, polylactic acid, Vicryl (polyglactin 910), synthetic skin (Biobrane), and freeze-dried dura
mater
*Co-polymers derived from polylactic acid and acetyl tributylcitrate resorbable membranes (Guidor membrane, no longer on the
market) and a poly-D,Llactide-co-glycolide (Resolut membrane, also no longer on the market) have shown significant gains in clinical
attachment and bone fill.
* Resorbable membranes marketed in the United States (US) include:
-OsseoQuest (Gore), a combination of polyglycolic acid,polylactic acid, and trimethylene carbonate that resorbs at 6 to 14months.
- BioGuide (Osteohealth), a bilayer porcine-derived collagen.
-Atrisorb (Block Drug), a polylactic acid gel.
-BioMend(Calcitech), a bovine Achilles tendon collagen that resorbs in 4 to18 weeks.
these, BioGuide is the most popular resorbable membrane.

*The use of membranes is usually combined with autogenous bone from adjacent areas or other graft materials and root
biomodifiers
*The potential of using autogenous periosteum as a membrane and also to stimulate periodontal regeneration has been explored in
two controlled clinical studies, one of grade II furcation involvements in mandibular molars and another of interdental defects.
*The periosteum was obtained from the patients palate by means of a window flap.
* Both studies reported that autogenous periosteal grafts can be used in GTR and result in significant gains in clinical attachment and
osseous defect fill.

5- Biomodification of Root Surface.

*Changes in the tooth surface wall of periodontal pockets (e.g., degenerated remnants of Sharpeys fibers, accumulation of bacteria
and their products, disintegration of cementum and dentin) interfere with new attachment.
*These obstacles to new attachment can be eliminated by thorough root planning.
*Several substances have been proposed for this purpose, including citric acid, fibronectin, and tetracycline.

Graft Materials and Procedures

The following classifications of bone graft material are important to note:
A) autografts are bone obtained from the same individual
B) allografts are bone obtained from a different individual of the same species.
C) xenografts are bone from a different species.

Bone graft materials are also evaluated based on :

1- Osteogenesis refers to the formation or development of new bone by cells contained in the graft.
2- Osteoinduction is a chemical process by which molecules contained in the graft (e.g., bone morphogenetic proteins) convert the
neighboring cells into osteoblasts, which in turn form bone.
3- Osteoconduction is a physical effect by which the matrix of the graft forms a scaffold That favors outside cells to penetrate the
graft and form new bone.

Periodontal defects as sites for transplantation differ from osseous cavities surrounded by bony walls.
Saliva and bacteria may easily penetrate along the root surface, and epithelial cells may proliferate into the defect, resulting in
contamination and possible exfoliation of the grafts. Therefore the principles established to govern transplantation of bone or
other materials into closed osseous cavities are not fully applicable to transplantation of bone into periodontal defects.
considerations that govern the selection of a material as follows:
biologic acceptability, predictability,clinical feasibility, minimal operative hazards, minimal postoperative sequelae, and patient
acceptance.
It is difficult to find a material with all these characteristics.
All grafting techniques require presurgical scaling, occlusal adjustment as needed, and exposure of the defect with a full
thickness flap.
The flap technique best suited for grafting purposes is the papilla preservation flap because it provides complete coverage of
the interdental area after suturing .
The use of antibiotics after the procedure is generally recommended
Autogenous Bone Grafts:
Bone from Intraoral Sites.
The method was revived by Nabers and OLeary in 1965, and numerous efforts have been made since that time to define its
indications andtechnique.
** Sources of bone include bone from healing extraction wounds, bone from edentulous ridges, bone trephined from within the jaw
without damaging the roots, newly formed bone in wounds, bone removed from tuberosity, and the ramus and bone removed
during osteoplasty and Ostectomy

Osseous Coagulum.
Technique described by Robinson using a mixture of bone dust and blood using small particles ground from cortical bone.
the particle size provides additional surface area for the interaction of cellular and vascular elements.
Sources of the graft material : lingual ridge on the mandible, exostoses, edentulous ridges, the bone distal to a terminal tooth,
bone removed by osteoplasty or ostectomy, and the lingual surface of the mandible or maxilla at least 5 mm from the roots.
Bone is removed with a carbide bur #6 or #8 at speeds between 5000 and 30,000 rpm, placed in a sterile dappen dish and used
to fill the defect.
The obvious advantage of this technique is the ease of obtaining bone from a area already exposed during surgery.
The disadvantages are its relatively low predictability and the inability to procure adequate material for large defects. And inability
to use aspiration during accumulation of the coagulum. Another problem is the unknown quantity and quality of the bone fragments
in the collected material.

Bone Blend technique :

To overcome disadvantages of osseous coagulum , the bone blend technique has been proposed.
The bone blend technique uses an autoclaved plastic capsule and pestle. Bone is removed from a predetermined site, triturated
in the capsule to a workable, plasticlike mass, and packed into bony defects.
Froum et al found osseous coagulumbone blend procedures to o be at least as effective as iliac autografts and open curettage.

Cancellous Bone Marrow Transplants.

can be obtained from the maxillary tuberosity, edentulous areas, and healing sockets.
The maxillary tuberosity frequently contains abundant cancellous bone, particularly if the third molars are not present.
After a ridge incision is made distally from the last molar, bone is removed with a curved rongeur.
Care should be taken not to extend the incision too far distally to avoid entering the mucosal tissue of the pharyngeal area.
the location of the maxillary sinus must be analyzed on the radiograph to avoid entering or disturbing it.
Edentulous ridges can be approached with a flap, and cancellous bone and marrow are removed with curettes, back-action
chisels, or trephine.
Extraction sockets are allowed to heal for 8 to 12 weeks before reentering and removing the newly formed bone from the apical
portion, which is used as the donor material.
Bone Swaging.
This technique requires an edentulous area adjacent to the defect, from which the bone is pushed into contact with the root
surface without fracturing the bone at its base.
Bone swaging is technically difficult, and its usefulness is limited.

Bone from Extraoral Sites.

In 1923, Hegeds also pioneered the use of extraoral sites as a source of bone for grafting into periodontal osseous defects, using bone from
the tibia. Schallhorn and Hiatt revived this approach in the 1960s using the iliac crest

Iliac Autografts.
This material has been used by orthopedic surgeons for years.
Data from human and animal studies support its use, and the technique has proved successful in osseous defects with various
numbers of walls.
It has also been successful in furcations and even supracrestally to some extent.
Some of the problems were postoperative infection, bone exfoliation, sequestration, varying rates of healing, root resorption,
and rapid recurrence of the defect (Figure 61-15).
Other problems were increased patient expense and difficulty in procuring the donor material.
the technique is no longer in use.

Allografts.
both allografts and xenografts are foreign to the patient and therefore have the potential to provoke an immune response.
Attempts have been made to suppress the antigenic potential of allografts and xenografts by radiation, freezing, and chemical
treatment.
Bone allografts are commercially available from tissue banks. They are obtained from cortical bone within 12 hours of the death
of the donor, defatted, cut in pieces, washed in absolute alcohol, and deep-frozen. The material may then be demineralized,
and subsequently ground and sieved to a particle size of 250 to 750 m and freeze-dried. Finally, it is vacuum-sealed in glass
vials.
steps taken to eliminate viral infectivity:
1- exclusion of donors from known high-risk groups and various tests on the cadaver tissues to exclude individuals with any
type of infection or malignant disease. (the risk of HIV infection in 1 in 1-8 million highly remote)
2- The material is then treated with chemical agents or strong acids to inactivate the virus, if still present.

types of allografts:
1- Undecalcified Freeze-Dried Bone Allograft.
 - FDBA (freeze-dried bone allograft) is considered an osteoconductive material, whereas demineralized FDBA (DFDBA) is
considered an osteoinductive graft.
- Laboratory studies have found that DFDBA has a higher osteogenic potential than FDBA and is therefore preferred.
2- Demineralized Freeze-Dried Bone Allograft.
- osteogenic potential; DFDBA tested against autogenous materials and showed it to have similar osteogenic potential.
- Demineralization in cold, diluted hydrochloric acid exposes the components of bone matrix, which are closely
associated with collagen fibrils and have been termed bone morphogenetic proteins (BMPs)**.
- ** A bone-inductive protein isolated from the extracellular matrix of human bones, termed osteogenin or BMP-3, has
been tested in human periodontal defects and seems to enhance osseous regeneration.
- Cortical DFDBA resulted in more desirable clinical results than cancellous DFDBA.
- histologic study in humans, showed new attachment and periodontal regeneration in defects grafted with DFDBA so
results in significant probing depth reduction, attachment level gain, and osseous regeneration.
Xenografts.
Bone products from other species have a long history of use in periodontal therapy.
Calf bone (Boplant), treated by detergent extraction, sterilized, and freeze-dried, has been used for the treatment of osseous
defects.
Currently, an anorganic**, bovine-derived bone marketed under the brand name Bio-Oss (Osteohealth) has been successfully
used both for periodontal defects and in implant surgery. It is an osteoconductive, porous bone mineral matrix from bovine
cancellous or cortical bone. The physical features permit clot stabilization and revascularization to allow for migration of
osteoblasts, leading to osteogenesis.

** Anorganic bone is ox bone from which the organic material has been extracted by means of ethylenediamine; it is then sterilized
by autoclaving The organic components of the bone are removed, but the trabecular architecture and porosity are retained.

Bio-Oss is biocompatible with the adjacent tissues, eliciting no systemic immune response. It has been used as a graft material
covered with a resorbable membrane (BioGuide). The membrane prevents the migration of fibroblasts and connective tissues
into the pores and between the granules of the graft.

After raising a flap, areas of Teeth undergo careful root Area is sutured.
periodontal bone loss are planing, and Bio-Oss graft is
clearly placed in the defects.

Nonbone Graft Materials.

These include sclera, dura, cartilage, cementum, dentin, plaster of Paris, plastic materials, ceramics, and coral-derived materials.
None offers a reliable substitute to bone graft materials.

Biologic Mediators:

Bone grafting attempts results in some regeneration, but this is usually limited to the base or apical aspect of the defect and the
resultant tissue formation is not sufficient in terms of quantity or predictability. So new therapeutic approaches for periodontal
regeneration have been sought.
The recognition that new tissues are formed by cell populations have resulted in efforts to stimulate the cells that are located in
the periodontal defect One way to stimulate these cells is to use proteins (growth factors) that can bind to surface receptors
on the cell membranes, which in turn trigger a series of events to occur that alter the genetic activity of the cell with the result
that cell behavior is stimulated.
 Cell behavior: either cellular proliferation or cellular differentiation. These biologic mediators have been used to stimulate
periodontal wound healing (e.g., promoting migration and proliferation of fibroblasts for periodontal ligament formation) or to
promote the differentiation of cells to become osteoblasts, thereby favoring bone formation.
These growth factors include platelet-derived growth factor (PDGF), insulinlike growth factor (IGF), basic fibroblast growth
factor (bfGF), BMP, and transforming growth factor (TGF).
GEM 21S: (recombinant human rhPDGF-BB); This commercial product is indicated in the treatment of intrabony periodontal
defects, furcation periodontal defects, and gingival recession associated with periodontal defects. But no regenerative indicatios
in alveolar bone defects and sinus augmentation.
GEM 21S consists of 0.5 cc of beta-tricalcium phosphate (-TCP) particles, (0.25 to 1.0 mm), which acts as the carrier, and 0.5 ml
rhPDGF-BB (0.3 mg/ml).
Besides the bone replacement graft materials, including autograft, allograft, xenograft, or alloplast, the formation of bone can
be enhanced when growth factors are used to stimulate osteoblast precursor or osteoblast cells and hence to push the bone
formation/bone resorption balance in favor of bone formation.
The bone morphogenetic proteins are a group of related proteins that are found in the body and are important for skeletal
development. As BMPs
BMP-2 has been shown to have some of the strongest bone producing activity; As a growth factor, the BMPs induce the
differentiation of mesenchymal stem cells to become bone producing osteoblast cells. BMPs are differentiation factors.
The extended release kinetics likely allow the undifferentiated mesenchymal cells migrating into the wound site to be exposed
to the growth factor.
The commercially available bone growth product contains rhBMP-2 combined with a bovine type I collagen sponge.

Enamel Matrix Proteins

Purified enamel matrix proteins have been extracted from porcine developing enamel, and their use for periodontal tissue
regeneration has shown mixed results in the numerous studies that have been conducted.
The enamel matrix proteins, mainly amelogenin, are secreted by Hertwigs epithelial root sheath during tooth development and
are known to induce acellular cementum formation. these proteins are believed to favor periodontal regeneration.
Example: trade name Emdogain. Ninety percent of the protein in this mixture is amelogenin, with the rest primarily proline-rich
non-amelogenins, tuftelin, tuft protein, serum proteins, ameloblastin, and amelin.
The technique using enamel protein derivatives, as described by Mellonig:
1- Raise a flap for reconstructive purposes
2- Remove all granulation tissue and tissue tags, The root surface should be thoroughly planed.
3- Completely control bleeding.
4- Demineralize the root surface with citric acid.
5- Rinse the wound with saline, and apply the gel to completely cover the exposed root surface.
6- Complete closure of the wound is necessary.
- A periodontal dressing is preferred to protect the wound.
- A systemic antibiotic coverage for 10 to 21 days is recommended.
the enamel matrix derivative is not osteoinductive, but it is osteopromotive in that it stimulates bone formation when
combined with demineralized FDBA.
As mentioned earlier, the type of attachment achieved during periodontal reconstructive therapy can only be determined
histologically.
Deep vertical bone loss distal Area flapped, root prepared, Postoperative photo 6 months Reentry surgery showing
to lower left central incisor. and defect filled with enamel later. extensive bone fill.
matrix protein (Emdogain).

Combined Techniques

To take advantage of the different bone graft materials and biologic mediators, clinicians have combined these graft materials
along with the use of membranes in a attempt to find a predictable technique to regenerate bone.
Example: in 1088; combination technique using graft material, root conditioning with citric acid, and coverage with a
nonresorbable membrane. More recently, with the advent of osteopromotive agents, such as the enamel matrix derivative
(Emdogain) and osteoconductive bovine-derived anorganic bone (Bio-Oss) graft materials, other combination techniques have
been advocated.
The combined use of these products, along with autogenous bone with resorbable membrane coverage, has resulted in an
increased percentage of cases with successful new attachment and periodontal reconstruction
the criteria that should guide the choice of treatment technique (by Froum):
1- the dimension and morphology of the defect (deeper lesions result in greater bone fill than shallower defects).
2- The number of walls in the defect75 (three-wall defects have greater potential to fill than two-wall or one-wall defects).
3- the amount of root surface exposed and the ability to obtain adequate flap coverage.
4- the angle of the defect to the long axis of the tooth193 (the smaller the angle, the better chance of success).