When not to use regenerative materials in periodontics
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“When not to use regenerative materials”- Guest lecture as a part of Dr NTRUHS Zonal CDE programme at Sri Sai College of Dental Surgery, Vikarabad, India on 26/5/2016. “Sinus lifts- Alternative techniques and Strategies” and “When not to use regenerative materials”- Guest lecture as a part of Dr NTRUHS Zonal CDE programme in G Pulla Reddy Dental College and Hospital, Kurnool, India on 07/10/2016.
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When not to use regenerative materials in periodontics
- 1. Dr R VISWA CHANDRA MDS;DNB Professor and Head Department of Periodontics SVSIDS, MBNR
- 2. CONDITION Periodontitis Periimplantitis Ridge augmentation Traumatic DEFECT Small intrabony defect Large osseous defect Extraction socket Ridge augmentation FACTORS Patient specific Environmental MATERIAL? Graft Growth Factor Combinational MODE OF ENTRY Flapless Conventional Minimally Invasive
- 3. Material: Zn-Monetite-HA / Follow up: 6 months Material: Novabone putty+Biomesh / Follow up: 8 months
- 5. *Dimitriou R et al. BMC Med. 2011 May 31;9:66. Busenlechner et al. Clin Oral Implants Res. 2009 Oct;20(10):1078-83
- 6. “The process of envelopment and interdigitation of the donor bone tissue with new bone deposited by the recipient" Hanser T, Khoury F. Int J Periodontics Restorative Dent. 2014 May-Jun;34(3):305-12. *Incorporation of ZN-MONETITE- HYDROXYAPATITE bone graft at 8 ½ months. *D Arun Kumar. Dissertation submitted to Dr NTRUHS.
- 7. Resorption by osteoclasts prior to bone deposition by osteoblasts LOW GRAFT RESORPTION RATE ensures that soft tissues are prevented from occupying the space where bone formation is intended Bone deposition by osteoblasts is facilitated by adequate blood flow
- 8. HAEMATOMA INFLAMMATION VASULARIZATION OSTEOCLASTIC ACTIVITY BONE FORMATION Elsalanty ME, Genecov DG. Craniomaxillofac Trauma Reconstr. 2009 Oct;2(3):125-34. ↑inflammatory cells ↑ fibroblasts Release of cytokines and growth factors
- 9. HAEMATOMA INFLAMMATION VASULARIZATION OSTEOCLASTIC ACTIVITY BONE FORMATION Infection, Micro motion of the graft ↑inflammation In Cortical grafts, vascularization is slower and occurs along Haversian Canals. In cancellous bone, it is because of Creeping Substitution.
- 10. HAEMATOMA INFLAMMATION VASULARIZATION OSTEOCLASTIC ACTIVITY BONE FORMATION IMMUNE REACTION Allo/Xenografts≠Genetically matched ↑Immune reaction Best Incorporation Autografts>Allografts>Xenografts Cancellous>Cortical Frozen>Freshly prepared
- 11. HAEMATOMA INFLAMMATION VASULARIZATION OSTEOCLASTIC ACTIVITY BONE FORMATION PRIMARY CLOSURE STABILTY OF INITIAL CLOT ANGIOGENESIS SPACE MAINTENANCE
- 12. Wang HL, Boyapati L. "PASS" principles for predictable bone regeneration. Implant Dent. 2006;15:8–17
- 14. INITIAL CLOT/FIBRIN CLOT/SURGICAL CLOT Mechanically Stable ~200 g at 3 days to 340 g at 5–7 days Cell and Growth factor Rich FIBRIN CLOT DISSOLVE~VASCULARIZATION THE CLOT SHOULD BE AS SMALL AS POSSIBLE* Polimeni G et al. Periodontology 2000, Vol. 41, 2006, 30–47. *Wikesjo UME, Nilveus R. J Clin Periodontol 1991: 18: 49–59.
- 15. Primary Closure/Primary Intention Sigurdsson et al 1994 Bone Graft Polimeni et al 2006 Fibrin clot ~ Smart clot Aukhil 2000
- 17. NOT achieving primary closure/Passive closure leads to* Loss of the SURGICAL CLOT Scarring/Delayed Healing Unpredictable Graft/GTR/GBR outcomes Fugazzotto PA. J Periodontol 1999; 70:1085-1097. Kim Y et al. Int J Oral Maxillofac Implants. 2015 Sep-Oct;30(5):1113-8.
- 18. Kim Y et al. Int J Oral Maxillofac Implants. 2015 Sep-Oct;30(5):1113-8. Greenstein G et al. J Periodontol. 2009 Jan;80(1):4-15. Wang HL, Boyapati L. Implant Dent. 2006;15:8–17 A regenerative procedure SHOULD NOT be performed when 1. Primary-Tension free closure cannot be obtained 2. No chance of advancing a flap for primary closure 3. Inadequate vestibular depth ~wound dehiscence 4. Tension in the wound is expected after graft/membrane placement
- 19. The chances of obtaining primary closure after graft placement when a sulcular incision is used is 20-40%. Kim Y, 2015; Liu Y, 2014; Kim YK, 2014; Torikai K, 2009. Greenstein G et al. J Periodontol. 2009 Jan;80(1):4-15. Wang HL, Boyapati L. Implant Dent. 2006;15:8–17
- 20. Amount of buccal flap advancement required is based on complexity of the Surgical procedure* *Greenstein G et al. Flap advancement: practical techniques to attain tension-free primary closure. J Periodontol. 2009 Jan;80(1):4-15. Minor Flap Advancement (<3mm) Moderate Flap Advancement (3 to 6 mm) Major Flap Advancement ( ≥7 mm)
- 23. 1. In conjunction with a horizontal incision across the edentulous area, create two vertical releasing incisions on the buccal aspect. 2. If vertical incisions do not facilitate optimal tissue advancement, hold the flap under tension with a tissue forceps, and score the periosteum across the whole flap. Moderate Flap Advancement 1 2
- 26. • If buccal vertical releasing incisions and periosteal fenestrations do not provide enough flap advancement to achieve tensionless primary closure, it is necessary to cut deeper into the sub mucosa. • This is done only when necessary as the patient experiences increased morbidity with regard to swelling, hemorrhage, and discomfort. Major Flap Advancement
- 28. “EXTREME” REMOTE INCISIONS Ashok Sethi, Thomas Kaus. Practical Implant Dentistry The Science and Art. Quintessence Publishing Co. Ltd, UK.
- 29. “EXTREME” REMOTE INCISIONS TentingGBR Periimplantitis
- 30. C R ER GBR
- 31. ER
- 34. At 1 month
- 35. Periimplantitis
- 42. Tenting
- 43. C R ER
- 48. AND A SPECTACULAR FAILURE……
- 55. At 10 days
- 57. AUTOGRAFTS do not show proper angiogenesis/neovascularisation when* 1. Not immediately harvested ~20 mins 2. Soaked in saline ~inactivates osteoprogenitor cells 3. Temperature exceeds 42°C 4. Complete degranulation is not possible ~reduced O2 tension *Lopez P et al. J Stem Cells Regen Med. 2007 May 16;2(1):178-9.
- 58. ALLOGRAFTS do not show proper angiogenesis/neovascularisation when* 1. There is graft micro motion ~in mobile teeth** 2. Complete degranulation is not possible ~reduced osteoinduction 3. If used fresh ~severe immune reactions *Park HC et al. Implant Dent. 2016 Apr 27. **Pandit N. Contemp Clin Dent. 2012 Oct-Dec; 3(4): 437–442.
- 59. ALLOPLASTS do not show proper angiogenesis/neovascularisation when* 1. They are not structurally strong ~as per strength BIOACTIVE GLASSES>HA>TCP>POP 2. Particle size <250µ and >750µ; Graft pore ratio is NOT 1:1 *Park HC et al. Implant Dent. 2016 Apr 27. **Pandit N. Contemp Clin Dent. 2012 Oct-Dec; 3(4): 437–442.
- 61. Turchi JL. Dent Today. 2008 Jun;27(6):112, 114. In Mobile tooth/Large defects in Post Teeth/Implants use Canc/Corticocanc Autograft & Canc Allografts If the endpoint is high quality bone use Alloplasts with the exception of Regular vs Irregular particle size
- 62. S
- 63. MEMBRANE ASSOCIATED • GTR • GBR NON MEMBRANE ASSOCIATED • Tenting Screws • Bone grafts (Polson and Proye, 1983). • Coronally advanced flap procedures (Becker, 2014). • Root conditioning (Nilveus, 1978; Polson and Proye, 1982). • Laser assisted de- epithelialization (Grossman and Israel, 2000). • Connective tissue grafts (Ellegaard, 1976; Bjorn, 1994).
- 64. For the predictable long-term success of regenerative materials, it is important to appreciate the available bone. It is important that the regenerative material used to fill defects correspond the number of walls of host bone remaining in contact with the graft. and gave a standard criteria in this regard.
- 65. Socket walls>1.5mm; Ideal condition as Growth Factors and RAP contribute to bone formation. Inexpensive HA to PRF will prevent the 60% facial bone loss.* an indication to use autogenous grafts or growth factor based substitutes. *Christopher Ogunsalu (2011). Bone Substitutes and Validation, Implant Dentistry - The Most Promising Discipline of Dentistry, Prof. Ilser Turkyilmaz (Ed.), ISBN: 978-953-307-481-8,
- 66. Additional active elements are beneficial in this graft since bone does not surround the defect. . *Christopher Ogunsalu (2011). Bone Substitutes and Validation, Implant Dentistry - The Most Promising Discipline of Dentistry, Prof. Ilser Turkyilmaz (Ed.), ISBN: 978-953-307-481-8,
- 67. *Christopher Ogunsalu (2011). Bone Substitutes and Validation, Implant Dentistry - The Most Promising Discipline of Dentistry, Prof. Ilser Turkyilmaz (Ed.), ISBN: 978-953-307-481-8, . Alloplasts are advantageous
- 68. BTE BONE TISSUE ENGINEERING aims to induce new functional bone regeneration via the synergistic combination of biomaterials, cells, and factor therapy. *Amini AR et al. Crit Rev Biomed Eng . 2012 ; 40(5): 363–408.
Editor's Notes
- Biological requirements for bone regeneration. Surgical procedures for ridge augmentation are designed based on biological principles of bone regeneration. First, space-maintenance where new bone formation is needed is achieved by use of grafts and/or membranes. In order for bone formation to occur, grafts need to be osteoconductive acting as a scaffold onto which bone resorption and deposition occurs. Most graft materials allow for their resorption by osteoclasts prior to bone deposition by osteoblasts (A). Since the turnover rate of soft tissues is higher than that of bone, grafts are used alone when their surfaces have low resorption rates, or in combination with membranes that separate the graft from soft tissues, when their surfaces have high resorption rates; This approach ensures that soft tissues are prevented from occupying the space where bone formation is intended (B); Bone deposition by osteoblasts is facilitated by adequate blood flow through the graft and osteoinductive properties of the graft that provide the growth factors necessary for osteoblast differentiation and function (C). Some grafts (autologous) act as osteogenic materials when they contain sufficient amount of osteoblasts precursors and growth factors.