Periodontal regeneration current concepts

1. Dr R Viswa Chandra MDS;DNB;PhD
Professor and Head
Department of Periodontics
SVS Institute of Dental Sciences
Mahabubnagar AP

2. INTRODUCTION
Periodontitis results in the
• Apical migration of junctional
epithelium over connective
tissue.
• Contamination of root surface
by bacteria and endotoxin
• Destruction of Progenitor
cells*
• Lack of chemotactic stimuli*
*Chen FM, Sun HH, Lu H, Yu Q. Stem cell-delivery
therapeutics for periodontal tissue regeneration.
Biomaterials. 2012 Sep;33(27):6320-44.

3. Multiple, specialized
cell types and
attachment
complexes
Avascular tooth
surfaces
Diverse microbial
flora
Stromal-Epithelial
Interactions
Slow and Varied Healing patterns
INTRODUCTION

4. PERIODONTAL REPAIR
• Repair > Regeneration*
• Common in conventional therapy
• Long JE because of rapid epithelial
turnover is the commonly seen
entity
• Reattachment of existing fibers
• Long JE is not inferior to a
dentogingival epithelium of
normal length+
*Ellegaard B et al. New attachment after treatment of interradicular
lesions. J Periodontol. 1973 Apr;44(4):209-17.
+Magnusson I et al. A long junctional epithelium--a locus minoris
resistentiae in plaque infection? J Clin Periodontol. 1983
May;10(3):333-40.

5. Whether a damaged tissue heals by regeneration or is
repaired depends upon two crucial factors*
(1) the availability of needed cell type(s), and
(2) the presence or absence of signals necessary to
recruit and stimulate these cells
These factors are not mutually exclusive
*Grzesik WJ, Narayanan AS. Cementum and periodontal wound healing and regeneration. Crit Rev Oral Biol
Med. 2002;13(6):474-84
WHY REPAIR?

6. Regeneration is distinct from tissue repair and is
characterized by replacement of the damaged tissues
with something that may be inferior to the original
tissue both structurally and functionally
To achieve successful periodontal regeneration, the
formation of a functional epithelial seal, the insertion
of new connective tissue fibers into the root, the
reformation of a new acellular cementum (New
Attachment) reformed on the root surface and the
restoration of alveolar bone height are required
PERIODONTAL REGENERATION

7. TRUE VS FALSE
PERIODONTAL REGENERATION
“Thus, if the ambition is to
regenerate the periodontal
ligament and the alveolar bone
that have been lost due to
periodontitis, it should aim at
reestablishing a new cementum
and neighboring cells”
Lars Hammarström. The 1998 Jens Waerhaug Lecture in
Periodontology. Scandinavian Society of Periodontology.

8. Some therapies have also
provided a promising
potential for significantly
improving clinical
parameters and
demonstrating substantial
“fill” of treated defects.
However, only limited
histologic evidence of true
regeneration has been
demonstrated with the
majority of these therapies.
TRUE VS FALSE
PERIODONTAL REGENERATION

9. “Despite conclusive evidence that some regeneration
may occur following regenerative procedures,
complete regeneration may be an unrealistic goal for
many situations due in part to the complexity of the
biological events, factors, and cells underlying
successful periodontal regeneration”*
It is emphasized that the three tissues of the
periodontium are dental tissues and that growth and
maintenance of the alveolar bone are regulated by
cells at the root surface+
*AAP. Position Paper Periodontal Regeneration. J Periodontol 2005;76:1601-1622.
+Grzesik WJ, Narayanan AS. Cementum and periodontal wound healing and regeneration. Crit Rev Oral Biol
Med. 2002;13(6):474-84.

10. PERIODONTAL REGENERATION
An Ambiguous term?

12. Carter DR, Beaupre GS, Giori NJ, Helms JA. Mechanobiology of skeletal regeneration.
Clin Orthop Relat Res. 1998; 355: S41–55.
ACHIEVING PERIODONTAL REGENERATION

13. Calori GM, Giannoudis PV. Bone Healing by the ‘Diamond Concept’.
Injury 2011 Nov;42(11):1191-3. doi: 10.1016/j.injury.2011.04.016.

14. Chen FM, Jin Y. Periodontal tissue engineering and regeneration: current approaches and expanding
opportunities. Tissue Eng Part B Rev. 2010 Apr;16(2):219-55.

15. Polson AJ. Periodontal Regeneration: Current Status and Directions
Quintessence Publishing Co Inc., U.S. (1 June 1994)

16. Polson AJ. Periodontal Regeneration: Current Status and Directions
Quintessence Publishing Co Inc., U.S. (1 June 1994)

18. Wang HL, Boyapati L. "PASS" principles for predictable bone regeneration.
Implant Dent. 2006;15:8–17

19. Buccal or lingual
grade II furcation
involvement
of first and second
mandibular/Maxillary
molars
Mesiopalatal grade
II furcation
involvement of
maxillary molars
1. Degree I and III
furcation involvement
2. Distopalatal and
Mesiopalatal grade II
furcation involvement
3. Buccal furcation
involvement with grade
II involvement of
distopalatal furcation or
a through-and-through
involvement between
two furcation entrances
4. Furcation
involvement of third
molars/premolars
Müller HP, Eger T. The overall significance of regenerative procedures in the
treatment of furcations. Quintessence Int. 1997 May;28(5):321-8.

21. Benatti BB et al. Physiological features of periodontal regeneration and approaches for periodontal tissue engineering
utilizing periodontal ligament cells. J Biosci Bioeng. 2007 Jan;103(1):1-6.
BENATTI (2007)* CLASSIFICATION
OF REGENERATIVE MATERIALS

22. Harvested bone grafts and graft substitutes
Growth factor-based bone graft substitutes
Cell-based bone graft substitutes
Ceramic-based bone graft substitutes
Polymer-based bone graft substitutes
Miscellaneous
LAURENCIN (2006)* CLASSIFICATION
OF REGENERATIVE MATERIALS
*Laurencin C, Khan Y, El-Amin SF. Bone graft substitutes.
Expert Rev Med Devices 2006; 3 : 49-57.

23. SCAFFOLDS
Natural Extracellular Matrices
Calcium Phosphate Scaffolds
Synthetic Polymer Scaffolds
Viral Vectors
Retroviral vector
Stem Cells
MSC
Non-Viral Vectors
PDGF, TGF
Dangaria SJ et al. Extracellular matrix-mediated differentiation of periodontal progenitor cells. Differentiation. 2009 Sep-Oct;78(2-
3):79-90. Taba M et al. Current concepts in periodontal bioengineering. Orthod Craniofac Res. 2005 Nov;8(4):292-302.

24. EFFECTS OF SCAFFOLDS
ON PERIODONTAL REGENERATION
WHOLE BONE LEVEL
Restoration of the
function and
structural support
by
Osteogenesis
Osteoinduction
Osteoconduction
Cell exclusion
ARCHITECTURAL LEVEL
Restoration of the
trabecular structure
of the bone
by
Osteogenesis
Osteoinduction
Cell exclusion
TISSUE LEVEL
Restoration of the
lamella and the
microarchitecture
By
Osteoinduction
Cell exclusion

25. CELL BASED MATERIALS
provide cells
that are able to
differentiate to
multiple cell
types to
promote
regeneration
to use cells
as carriers to
deliver growth
or cellular
signals

27. Exhibit stem cell
functionality
Secrete
growth factors
Immuno
modulation
Rios HF et al. Cell- and gene-based therapeutic strategies for periodontal regenerative
medicine. J Periodontol. 2011 Sep;82(9):1223-37.
contains several heterogeneous
cell populations, ranging from
osteogenic lineages
putative stem cell marker
STRO-1 and the perivascular cell
marker CD146
Expresses IGF, PDGF-BB and
TGF-β
Immune inhibiting and
stabilizing effect

28. BIOLOGIC FACTORS
ANGIOGENIC
Factors
FGF, PDGF
SIGNALING
Factors
EMD, BMP

29. Benatti BB et al. Physiological features of periodontal regeneration and approaches for periodontal tissue
engineering utilizing periodontal ligament cells. J Biosci Bioeng. 2007 Jan;103(1):1-6.

30. CONCLUSION
The future of the regeneration may depend on
the merging of various technologies and
biological concepts, including the possible use
of biological barriers, various bone and
periodontal growth inducers, and artificial
matrices that will attract or carry the cells
necessary for regeneration.

31. *Elangovan S, Avila-Ortiz G, Johnson GK, Karimbux N, Allareddy V. Quality assessment of systematic reviews on
periodontal regeneration in humans. J Periodontol. 2013 Feb;84(2):176-85.
*
Too many ingredients spoil the broth?