Periodontal Regeneration (Lecture) 2017 PDF

PERIODONTAL REGENERATION
Periodontal Regeneration Enhanced Dr. Vijay Desai

What is the
ideal goal
of
Periodontal
Therapy ???

REPAIR
or ???
REGENERATION

REPAIR
Can be defined as the healing

of a wound by tissue that does
not fully restore the previous
architecture or function
( Glossary of Periodontal term
1992)

REGENERATION
is defined as a reproduction or
reconstruction of a lost or
injured part in such a way that
the architecture and function of
the lost or injured tissues are
completely restored
( Glossary of Periodontal term
1992)
PERIODONTAL REGENERATION
OPTIONS

First generation
Second generation
Third generation
Fourth generation

I. Removal of Junctional &
Pocket epithelium
A ) Non Surgical Methods
Non graft associated Scaling, Root planing
new attachment Chemotherapeutic Agents
B ) Surgical Methods
Curettage, Gingivectomy, Flap, etc
II. Root surface conditioning
Citric Acid, Fibronectin
Tetracycline
III ) Root surface conditioning
Citric Acid
Fibronectin
Tetracycline
Healing by formation
of Long Junctional Epithelium
Limited amount of Bone,

Cementum & P.L. regeneration
Autograft: is a tissue graft obtained graft associated
from one site within same individual new attachment
Cortical bone Chips
Osseous Coagulum
Bone blend
Intra & extra oral Cancellous
Bone Marrow
Isograft: is a tissue graft obtained
from individual of identical genetic
composition e.g. identical twins

Allograft: is a tissue graft obtained
from individual of same species but
of non identical genetic composition
Freeze Dried Bone

Decalcified Freeze-dried Bone
Xenograft :Graft obtained from
individual of different species e.g.
Bovine Bone, Kiel Bone, Os Puram

Synthograft ( Alloplast)
Absorbable
ceramics, beta tricalcium phosphate,
Hydroxyapatite, calcium sulfate and
calcium carbonate.
Nonabsorbable
hydroxyapatite, bioglass and
calcium-coated polymer of
hydroxyethylmethacrylate and
polymethylmethacrylate.

Sclera
Cartilage
Ceramics
Osteoinduction
Is a chemical process by which molecules
contained in the graft (bone morphogenetic
proteins or BMPs) convert the neighboring
cells into osteoblasts, which in turn form
bone eg. Decalcified Freeze dried bone
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. eg. Beta tricalcium phosphate,
Hydroxyapatite,

Biologic acceptability
Predictability
Clinical feasibility
Minimal operative hazards
Minimal postoperative sequelae
Patient acceptance & COST
Deep intra osseous angular
defects
Furcation Involvement
Ridge Augmentation
Shallow-Wide Crater defects
Edentulous ridges
Healing extraction socket
Exostosis
Lingual ridge of mandible
Bone distal to terminal tooth.
Mixer of bone particles and blood forms osseous
coagulum.
ADVANTAGES
the particle size is that it provides additional surface area
for the interaction of cellular and vascular elements.
Ease of obtaining bone from already exposed surgical sites
DISADVANTAGE
Relatively low predictability and inability to procure
adequate material for large defects
SOURCE
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.
PROCEDURE
Bone is removed with a carbide bur #6 or #8 at speeds
between 5000 and 30,000 rpm, placed in a sterile dappen
dish or amalgam cloth, and used to fill the defect
BONE BLEND: This technique require autoclaved
plastic capsule and pestle.
Bone is removed from intra-oral sites by chisels or
ronger .The pestle and bone fragments are placed in
the capsule, and few drops of saline are added. The
capsule is closed, wrapped in sterile gauze, and
placed in triturator. The bone is triturated for 60
seconds.
Trituration makes the bone fragments plastic like
osseous mass
VBD
AUTOGENOUS BONE GRAFTING PROCEDURE
PRE OPERATIVE CLINICAL PROBING DEPTH FILLED WITH GRAFT
POST OPERATIVE CLINICAL PROBING DEPTH BONE FILL

Bone from the edentulous area adjacent to the
defect is pushed into contact with root surface
without fracturing the bone from it is base.
EVALUATION OF NEW ATTACHMENT AND BONE REGENERATION
Clinical Methods
Radiographic Methods
Surgical Reentry
Histologic Methods
Abilityfor regeneration of Cementum
& Periodontal ligament is very limited
Ankylosis

Prevention of epithelial migration
Guided Tissue Regeneration

( GTR)

Melcher' suggested that……

Players in the RACE
LONG JUNCTIONAL
EPITHELIUM
1. Epithelium
2. Gingival Connective Tissue

ROOT RESORPTION /
3. Alveolar Bone ANKYLOSIS
4. Periodontal Ligament
NEW ATTACHMENT

The method of prevention of
epithelial migration along the
cemental wall of the pocket by
placing a barrier in between the root
surface & the epithelium & allowing
only the cells from periodontal
ligament to repopulate the root is
called guided tissue regeneration
(GTR)
a. Polytetrafluoroethylene (e-PTFE)
type (WL Gore)
b. Titanium-reinforced
polytetrafluoroethylene type
(WL Gore)

a. Collagen type
KOKEN tissue guide (Koken) Paroguide (Lyon)
b. Synthetic polymer type (lactate-glycol compound)
GC membrane (GC)
Resolute (WL Gore)
Vicryl (Ethicon)
Atrisorb (Atrix)
Guidor (Guidor)
Application of the membrane is often
difficult while there is substantial
variation in clinical predictability,
degree of efficacy and histologic
outcomes.
Membrane Exposure
Growth Factors
Platelet – derived growth factors
Insulin- like growth factors
Transforming growth factors
&
Extra Cellular Matrix derivative ( EMD)

Periodontal Regeneration Enhanced

What is Emdogain ?
ENAMEL MATRIX PROTEIN

(Amelogenins in an aqueous
viscous solution of propylene
glycol alginate at pH 5.5.- 6.7)

Made from ???
amelogenins are
extracted from
the developing
enamel of porcine
origin
AVAILABLE AS
ready to-use,
Prefilled syringes

PROPERTIES
it is radiolucent
and degraded by
the body WITHin
two weeks
( Resorbable)
Enamel matrix
derivative
does not “fill
the defect”

the term “defect fill” (sometimes used as a
clinical measurement in regenerative therapy) does
not distinguish newly regenerated bone
from graft particles.
In EMD-treated defects, the bone

eventually detected on radiographs is
all newly regenerated bone.

Hertwig's epithelial root sheath
Enamel matrix proteins P. L. & Bone
Acellular cementum

Y. Hejil, Malmö
Days Weeks Months One Year

The enamel matrix
protein forms a Bone formation A new attachment
starts at the A new functional
matrix on the root with cementum and attachment is
surface. Mesenchymal Emdogain® ligament is formed
treated root surface achieved with time.
cells migrate into the along the treated
lesion, attach to the and subsequently root surface.
surface and start to new alveolar bone
proliferate. will fill the defect.
Class I & II
Furcations

Infrabony
osseous defects
(2 – 3 wall defects)

Class I / II
Gingival Recession

UNCONTROLLED DIABETES
UNCONTROLLED SYSTEMIC DISEASES OR

DISORDERS
CHRONIC HIGH-DOSE STEROID THERAPY

BONE METABOLIC DISEASES
RADIATION OR OTHER
IMMUNOOPPRESSIVE THERAPY
INFECTIONS OR VASCULAR
IMPAIRMENT AT THE SURGICAL SITE

PURPOSE
EDTA gel removes the

smear layer
It also exposes the

collagenous matrix of the
root surface without
risking necrosis of
surrounding tissues
First visit 8 years

Baseline 12 month follow up
Controlled Clinical Studies on Treatment of Intrabony Defects With EMD (mean SD)
Evaluation Defect N Defect PD (mm)
Reference Period* Morphology† Defects Depth (mm) Initial Residual

Reduction
Heijl et al.35 1997 8 1-w 2-w 34 4.8 ± 1.5 7.8 ± 1.1 4.4 ± 1.0 3.3 ± 1.3
Silvestri et al.49 2000 12 10 5.9 ± 1.8 7.7 ± 2.2 2.8 ± 0.9 4.8 ± 1.6
Froum et al.50 2001 12 53 5.6 ± 1.2 8.0 ± 1.5 3.1 4.9
Pietruska51 2001 12 2-w 3-w 12 8.0 ± 2.2 4.0 ± 2.2 4.0
Sculean et al.52 2001 12 1-2-w 2-w 3-w 14 3.8 ± 1.4 8.4 ± 1.9 4.3 ± 1.2
4.1 ± 1.7
Zucchelli et al.53 2002 12 30 6.1 ± 1.3 9.2 ± 1.0 4.0 ± 0.7 5.1 ± 0.7
Velasquez et al.54 2002 6-8 2-3-w 3-w 16 4.9 ± 1.5 6.6 ± 1.3 2.8 ± 0.8 3.8 ± 1.2
Tonetti et al.55 2009 12 1-w 2-w 83 5.8 ± 2.1 8.0 ± 1.5 4.1 3.9 ± 1.7
Weighted mean ± SD 5.4 ± 0.8 7.9 ± 0.8 3.9 ± 0.8 4.0 ± 0.9
REGENERATIVE
TRIAD Scaffolds
( Bone grafts, Collagen
& Synthetics)
REGENERATION
(Time & Environment)
CELLS Signaling
Cementoblast Molecules ( Growth
Osteoblast & Fibroblsts Factors)

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PERIODONTAL REGENERATION

Periodontal Regeneration Enhanced Dr. Vijay Desai

Periodontal Regeneration Enhanced Dr. Vijay Desai

Periodontal Regeneration Enhanced Dr. Vijay Desai

Can be defined as the healing

Periodontal Regeneration Enhanced Dr. Vijay Desai

Periodontal Regeneration Enhanced Dr. Vijay Desai

Periodontal Regeneration Enhanced Dr. Vijay Desai

Limited amount of Bone,

Periodontal Regeneration Enhanced Dr. Vijay Desai

Freeze Dried Bone

Periodontal Regeneration Enhanced Dr. Vijay Desai

Periodontal Regeneration Enhanced Dr. Vijay Desai

Periodontal Regeneration Enhanced Dr. Vijay Desai

PRE OPERATIVE CLINICAL PROBING DEPTH FILLED WITH GRAFT

POST OPERATIVE CLINICAL PROBING DEPTH BONE FILL

Periodontal Regeneration Enhanced Dr. Vijay Desai

Guided Tissue Regeneration

Periodontal Regeneration Enhanced Dr. Vijay Desai

Periodontal Regeneration Enhanced Dr. Vijay Desai

2. Gingival Connective Tissue

Periodontal Regeneration Enhanced Dr. Vijay Desai

Periodontal Regeneration Enhanced Dr. Vijay Desai

Extra Cellular Matrix derivative ( EMD)

Periodontal Regeneration Enhanced Dr. Vijay Desai

ENAMEL MATRIX PROTEIN

Periodontal Regeneration Enhanced Dr. Vijay Desai

Periodontal Regeneration Enhanced Dr. Vijay Desai

Periodontal Regeneration Enhanced Dr. Vijay Desai

In EMD-treated defects, the bone

Periodontal Regeneration Enhanced Dr. Vijay Desai

Enamel matrix proteins P. L. & Bone

Periodontal Regeneration Enhanced Dr. Vijay Desai

Days Weeks Months One Year

Periodontal Regeneration Enhanced Dr. Vijay Desai

Periodontal Regeneration Enhanced Dr. Vijay Desai

Periodontal Regeneration Enhanced Dr. Vijay Desai

UNCONTROLLED SYSTEMIC DISEASES OR

CHRONIC HIGH-DOSE STEROID THERAPY

Periodontal Regeneration Enhanced Dr. Vijay Desai

Periodontal Regeneration Enhanced Dr. Vijay Desai

EDTA gel removes the

It also exposes the

Periodontal Regeneration Enhanced Dr. Vijay Desai

Reference Period* Morphology† Defects Depth (mm) Initial Residual

Froum et al.50 2001 12 53 5.6 ± 1.2 8.0 ± 1.5 3.1 4.9

Pietruska51 2001 12 2-w 3-w 12 8.0 ± 2.2 4.0 ± 2.2 4.0

Periodontal Regeneration Enhanced Dr. Vijay Desai

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