Periodontal Regeneration Techniques

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CONTENTSCONTENTS

1.Introduction
2.Terminology
3.Reconstructive periodontal surgery
4.Possible outcomes of periodontal therapy / periodontal wound healing
5.Assessments of periodontal regeneration
6.Techniques for reconstructive osseous surgery
7.Root biomodification
8.Guideid tissue regeneration
9.New Approaches to Periodontal Regeneration:
10.Biologic mediators
11.Conclusion
12.References

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• Goals of periodontal therapy is to restore the lost supporting tissues and
regenerate a functional periodontium.
• The conventional periodontal treatment fails to achieve this goal and is
restricted to only arresting the further loss of supporting tissues.
• Formation of new bone and new cementum with supportive periodontal
ligament, is a possible objective of several periodontal therapeutic
modalities, outcomes of such modalities are not always predictable.
INTRODUCTIONINTRODUCTION

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TERMINOLOGIESTERMINOLOGIES
• Regeneration : Is defined as 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.
(GPT 1992)
• Repair: Defined as healing of wound by tissue that does not fully
restore the architecture or function of the part.
(GPT 1992)
• Reattachment: It refers to repair in areas of the root not
previously exposed to the pocket, such as after surgical
detachment of tissues or following traumatic tears in cementum,
tooth fractures or the treatment of periapical lesions.
(Carranza 10th
edition)
• New Attachment: Is the embedding of new periodontal ligament
fibres into new cementum and attachment of the gingival
epithelium to a tooth surface previously denuded by disease.
(Carranza 10th
edition)

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CRITERIA FOR REGENERATIONCRITERIA FOR REGENERATION
• Controlled animal histological studies demonstrating formation of new
cementum, PDL and bone.
• Human histological specimens demonstrating formation of new
cementum, PDL and bone coronal to a notch indicating the apical
extension of the periodontitis affected root surface.
• Controlled human clinical trials demonstrating improved clinical probing
attachment and bone.
AAP 1996

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RECONSTRUCTIVE PERIODONTALRECONSTRUCTIVE PERIODONTAL
SURGERYSURGERY

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PERIODONTAL WOUND HEALINGPERIODONTAL WOUND HEALING
• Formation of fibrin clot between the flap margin and the root surface,
followed by replacement of this fibrin clot by a CT matrix attached to the
root surface.
• When this ‘fibrin linkage’ is maintained, a new CT attachment to the root
surface develops. If the fibrin linkage is disrupted, a long junctional
epithelium type attachment results.
(JP 2005 Academy report)

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• 1976, Melcher pointed out that cells that repopulate the root surface
after periodontal surgery determines the nature of the attachment that
will form.
• Oral Epithelium
• Gingival connective tissue
• Bone
• PDL

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PERIODONTAL REGENERATIONPERIODONTAL REGENERATION
• Clinical methods
• Radiographic methods
• Surgical re-entry
• Histologic methods

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TECHNIQUES FOR REGENERATIONTECHNIQUES FOR REGENERATION

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Non-Graft-Associated New AttachmentNon-Graft-Associated New Attachment

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1.1. Removal of Junctional and Pocket EpitheliumRemoval of Junctional and Pocket Epithelium
A. Curettage
• Not a Reliable procedure.
• Ultrasonic methods and rotary abrasive stones have also been used.
• The healing following curettage is most seen as long junctional
epithelium, which is the same as a result obtained with SRP alone (Caton
1980).
• So, the theoretical clinical advantage of curettage over SRP alone was
eliminated when CT attachment was shown to be unattainable goal
(Caton 1980).

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B. Chemical Agents
1.Sodium Sulfide
2.Phenol
3.Camphor
4.Antiformin
5.Sodium Hypochlorite
Disadvantage
•Depth of action cannot be controlled.

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C. Surgical Techniques
ENAP: Excisional new attachment procedure
•Internal bevel incision performed with a surgical knife, followed by removal
of the excised tissue.
•No attempt is made to elevate a flap.
•Scaling and root planing, interproximal sutures are used to close the wound .
LASER Assisted ENAP: (Robert H. Gregg et al, 2003)

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Modified Widman Flap (Ramfjord and Nissle 1974)

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2. Prevention of Epithelial Migration:
Elimination of junctional and pocket epithelia may not be sufficient because
the epithelium from the excised margin may rapidly proliferate to become
interposed between the healing connective tissue and the cementum.
Interdental denudation and soft tissue autogenous graft
•Method proposed to prevent or retard the migration of the epithelium
consists of total removal of the interdental papilla covering the defect and its
replacement with a free autogenous graft obtained from the palate.
•During healing, the epithelium necroses, and its migration is retarded.

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Coronal displacement of the flap
•Periosteum has long been viewed as having regenerative potential.
•Combination of
1.Cellular activity of the periosteum and
2.Barrier type effect by the repositioned periosteum.
•This procedure positions the flap margin away form the ‘critical healing area’
(the furcation site) and secures it in that position during early healing time
patients.
•Re-entry results form 3 studies indicated approximately 50-65% by volume,
bone fill in Class II mandibular furcation defects. Thus, horizontal portion of
furcation defect was closed via bone-fill.
(Ellegaard B et al 1974, Fuentes P et al. 1993, Melcher AH. 1976)

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LIMITATIONS -
•A large number of patients with a longer follow-up period, appears
necessary to fully evaluate its efficacy.
•Before re-entry, the large majority of these ‘closed’ defects demonstrated
residual furcation involvement clinically.
(Position Paper, JP
2005)

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ROOT BIOMODIFICATIONROOT BIOMODIFICATION
• 1800s as a substitute for scaling and calculus removal.
• In the 1890s - effectiveness of acid as an adjunct to mechanical removal of
calculus and cementum for periodontal reattachment.
• Urist (1970,1973) - 0.6N HCl and transplanted in vivo in various animal
models.
• It was suggested that the dentin matrix contained a protein or a series of
proteins that possessed the ability to induce differentiation of cells.
• The inductive property was only available following acid demineralization
suggesting that the inorganic component of dentin may obscure potential
inductive proteins associated with the organic component.

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RATIONALE
•Zander et a.l (1962)
•Morris and Tomson (1963)
•Demineralized surface - rough and irregular - impede epithelial cell
migration.
•Removes endotoxin from the root surface thus enabling better soft tissue
attachment. (Aleo 1975)
•Antibacterial effect.

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CITRIC ACID
•Cementogenesis & new attachment & the CC was the acid of choice , with
an optimal application time of 2 to 3 minutes.
•Antibacterial effect (Daly, 1982)
•Root detoxification (Aleo and colleagues,1975)
•Exposure of root collagen and opening of dentinal tubules (Polson and
colleagues, 1984)
•Removal of the smear layer (Polson and col-leagues, 1984)
•Initial clot staitaibilization (Wikesjo, 1991)
•Demineralization prior to cementogenesis (Register, 1975,1976)
•Enhanced fibroblast growth and stability (Boyko and colleagues, 1980)
•Attachment by direct linkage (Stahl and Tarnow, 1985; Stahl, 1986) or
periodontal without cementogenesis (Levine and Stahl, 1972; Masileti, 1975)
•No adverse effects to either the pulp (Hagner and Polson, 1986) or
periodontal tissues (Polson and Haynes, 1986) have been reported.

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Tetracycline Hydrochloride
•Demineralization (Bjorvatn, 1983)
•Detoxification of the root surface (Terranova and colleagues, 1986)
•Permits attachment by direct linkage with or without cementogenesis (Alger
and col-leagues, 1990)
•Antibacterial (Baker and colleagues, 1983a)
•Exposure of root collagen and opening of the dentinal tubules; removal of the
smear layer (Wikesjo and colleagues, 1986)
•Anticollagenase activity (Golub and col-leagues, 1984)
•Positive effects when placed in bone grafts (Al-Ali and colleagues, 1989;
Papelarsi and colleagues, 1991)
•Substantively antibacterial for 2 to 14 days (Baker, 1983b)
•Enhances bone repair in extraction sockets (Hars and Massler, 1972)
•Binds more fibronectin to the de-mineralized surface (Terranova, 1986)

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Ethylenediaminetetraacetic Acid
•24% & pH (7.0).
Advantages:
•Equally effective in smear layer removal (Blomlof and colleagues, 1997)
•Exposes more intact collagen bundles (Blomlof and colleagues, 1996)
•Less necrosis of the periodontal tissues (Blomlof and Lindskog, 1995a)
•Does not dissolve root collagen fibers (Blom-lof and colleagues, 2000)
•Greater histologic attachment with less junc-tional epithelium formation
(Blomlof and colleagues, 1996)

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FIBRONECTIN
•Cell-cell and cell-substrate adhesiveness (Pearlstein 1976; Yamada and
Weston 1974), cell spreading, locomotion, and morphology (Ali et al 1977,
Yamada et al 1978).
•Several functions involved in the body’s response to injury during wound
healing, clot formation, and hemostasis (Bitterman et al 1983; Kurkinen et al
1980).
•Advantages:
•Fibronectin stimulates this growth from the PDL (Karring et al, 1986)
•Favors the growth and attachment of fibroblasts over epithelial cells to the
root surface (Terranova & Martin, 1982).
•Speeds the linkage process by being chemoattractive for fibroblasts
(Mensing et al, 1983), acting as a tissue adhesive (Boyko et al, 1980), and
stabilizing the clot between the exposed root surface collagen and new fibers
within tissue (Clark et al, 1982)

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• The use of citric acid, tetracycline, or EDTA to modify the root surface
provides no beneﬁt of clinical signiﬁcance to regeneration in patients with
chronic periodontitis.
(Marrioti 2003)

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GUIDEID TISSUE REGENERATION
AAP : Guided tissue regeneration is defined as those procedures used to
regenerate lost periodontal tissue through differential tissue response.

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CC
LL
AA
SS
SS
II
FF
II
CC
AA
TT
II
OO
NN
Gottlow (1991)

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Non resorbable membranes
•Silicon sheets
•Cellulose acetate lab filters
•Millipore filters
•Polytetraflouroethylene (PTFE) membrane
•Rubber dam.
Resorbabale membranes

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FACTORS THAT CAN ADVERSELY AFFECT
CLINICAL OUTCOMES
WANG H L 1998

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ADVANTAGES OF ABSORBABLE BARRIER MATERIALS VERSUS
NONABSORBABLE MATERIALS
1. Be more tissue-friendly and
integrated with host tissue
2. Enhance tissue coverage and
reduce barrier exposure
3. Resist microbial colonization
4. GTR = guided tissue
regeneration.
1. Reduce operatory time .
2. Reduce overall treatment
morbidity
3. Increase patient acceptance of
GTR-type procedures
4. Reduce risk of loss of
regenerated attachment owing to
reentry surgery

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HEALING
• By 9 weeks defects partly or completely filled with new connective tissue
with a thin epithelial lining interposed between the tissue and the root
surfaces in the coronal parts of the defects is seen.
• Formation of new bone started in apical parts of defects and is in
continuity with old bone and always lined with osteoblasts.
• Resorption of most part of collagen membrane is seen by 8 weeks,
although some portions may still show the strands of collagen undergoing
resorption.
• Histologically, the use of GTR in gingival recession defects results in a
limited regeneration of the periodontal attachment, including new
cementum formation with inserting periodontal ligament fibers.

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CLINICAL APPLICABILITY
•In the treatment of intrabony defects, GTR procedures, as compared with
open flap debridement controls, resulted in significantly more favorable gains
in CAL and PD reduction.
•In the treatment of furction defects, GTR procedures, as compared with
open flap debridement controls, resulted in significantly more favorable gains
in vertical probing attachment level, reductions in vertical probing depth, and
improvement in horizontal open probing attachment measurements.
•In the treatment of intrabony defects, meta-analysis did not show any
statistically significant superior results among barrier types evaluated.
•In the treatment of furcation defects, type of barrier employed did affect the
surrogate variable of vertical probing attachment level, since vertical probing
attachment level was enhanced only with the use of ePTFE and polymeric
barriers.
•The use of augmentation materials enhances the regeneration outcome in
the treatment of furcation defects treated with GTR.
Murphy 2003

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Department studies:
1.Dr. Nitin Kullar and Dr. Shobha Prakash, 2005
•Clinical and radiographically evaluated absorbable collagen membrane in
class II furcation defects.
•5 patients were selected who were having 16 mandibular class II furcation
defects.
•8 sites with OFD + GTR (Biomend)
•8 sites with OFD
•Increase horizontal bone repair & CAL with use of absorbable collgen
membrane.
2. Dr. Balsubramanya and Dr. Shobha Prakash, 2004
•Clinical and radiographic evaluation of mandibular class II furcation
treatment with bioresorbable membrane – vicryl mesh.
•7 patients with 22 furcation defects.
•11 sites with OFD + GTR (Vicryl mesh)
•11 sites with OFD
•Barrier membrane beneficial when compared with OFD
alone

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SURGICAL CONSIDERATIONSSURGICAL CONSIDERATIONS
• Modified papilla preservation technique.
• Simplified papilla preservation technique.

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NEW APPROACHES TONEW APPROACHES TO
PERIODONTAL REGENERATIONPERIODONTAL REGENERATION
• “periodontal bone defects are treated with same type of bone grafting
material, with the expectation that bone, cementum and periodontal
ligament will all be formed.”
• 2 main approaches:-

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POLYPEPTIDE GROWTH FACTORSPOLYPEPTIDE GROWTH FACTORS
Platelet-derived growth factor

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Fibroblast growth factors
Mitogenic and chemotactic for fibroblasts, chondrocytes, osteoblasts,
and endothelial cells

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Transforming growth factor-β
•Platelets, osteoblasts, and macrophages
•Latent form in bone
•Low ph during osteoclastic bone resorption, which is sufficient to activate
latent TGF-β stored in the bone.

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Bone Morphogenetic Proteins
•15 bmps
•TGF-β superfamily
•Uncommitted mesenchymal stem cells into chondroprogenitor and
osteoprogenitor cells.
•Promote an osteoblastic phenotype in undifferentiated mesenchymal
progenitor cells and stimulate new bone growth.
In vitro studies
•Osteoblasts, cementoblasts, and their progenitors arise from the endosteal
spaces of the alveolar process.
•Stimulate and maintain the osteoblast phenotype.
•Action limited to cartilage and bone-forming cells.

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In vivo studies
•BMP-treated specimens exhibited a significantly greater coronal extension of
new attachment and alveolar bone regeneration than controls treated with
collagenous matrix only.
Ripamonti et al., (1994)
•Increase the rate of osseointegration of implants
(Wang et al., 1994)
Department study: Dr. Ganesh & Dr. Kala Bhushan, 2009
•Clinical evaluation of rhBMP-2 (ALTIS – OBM PERIO) in treatment of human
periodontal osseous defects.
•32 patients wit 20 experimental and 13 control sites.
•Mean attachment gain at 6months not significant but significant at 9
months.
•Original bone fill at 6 months and 9 months statistically significant.

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Emdogain
•Acetic acid extracted protein preparation from developing porcine tooth
buds.
•Major constituents are amelogenins (90%) & enamelins (10%), which are
highly hydrophobic proteins that aggregate and serve as nidus for
crystallization.
•Induces cementum formation followed by periodontal regeneration.
•A Systematic review (Gianobile etal 2003) concluded that there is evidence
supporting the use of EMD in periodontal osseous defects to improve CAL
and reduce PD, although long term benefits have not been established.
Where as acc to some, there was no added adv of using Emdogain over
surgical debridement
(Hagenaars 2004)

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DEPARTMENT STUDY: Dr. Kinnari Shah and Dr. Shobha Prakash, 2001
•Clinical and radiographic evaluation of emdogain as a periodontal
regenerative material in treatment of interproximal vertical defects.
•8 patients with 16 sites having bilateral vertical defects.
•No additional advantage of using emdogain as compared to sites with
surgical debridment alone.

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Platelet rich plasma
•Consists of PDGF, IGF and TGF-b & fibrinogen.
•In clinical use, Calcium and thrombin are added to the PRP preparation to
activate the proteolytic cleavage of fibrinogen into fibrin. Fibrin formation
initiates clot formation which in turn, initiates wound healing.
•Palmisano et al (2002) used canine model to investigate the effect of PRP
when combined with mineralized bone, showed no benefit with addition to
PRP.
•Dori et al (2007) clinically compare treatment of deep intra-bony defects
with Natural Bone Mineral (NBM) +PRP+GTR with NBM+GTR and shown that
the use of PRP has failed to improve the results obtained with NBM+ GTR.

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ConclusionConclusion
• Over the last 3 decades, the periodontal literature has been filled with
numerous reports related to PD regeneration.
• Current regenerative procedures can lead to PD regeneration,the use of
GTR and Biologic modifiers can enhance these results.
• The crucial challenge for the periodontist is to critically assess whether a
periodontal defect can be corrected with regenerative approach or
whether it would be better managed with other treatment options.

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• Periodontal Regeneration-Polson
• CARRANZA 10TH
EDITION ---- Clinical Periodontology
• Naoshi Sato – periodontal surgery A Clinical atlas
• Periodontal Therapy- Nevins & Mellonig
• Clinical Periodontology & Implant Dentistry (5th
edition) J. Lindhe
• Cohen RE et al. Glossary of periodontal terms. 4th
edition. Chicago: The
American Academy of Periodontology; 2001.
• Atlas of Cosmetic & Reconstructive Periodontal Surgery, Edward S. Cohen,
2nd
edition.
• Consensus report. Periodontal regeneration around natural teeth. Ann
Periodontol 1996;1:667-670.
• Bowers GM, Chadroff B, Carnevale R, et al. Histologic evaluation of new
attachment apparatus formation in humans. Part I. J Periodontol 1989;
60:664-674.
• Dr. Paulo Camargo Reconstructive Osseous Surgery: (intrenet)
• Wang H L jp 2005 ; periodontal regeneration . a positional paper.
REFERENCESREFERENCES

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• Sullivan H C, and Dragoo M R.Regenerative techniques in periodontal therapy.
Dent Clin North Am 1976; 20: 131.
• Karring T, Nyman S, Thailander B,and Magnusson I. Bone regeneration in
orthodontically produced alveolar bone dehiscences. J Periodontol 1982; 17: 309.
• Polson AM, Heijl LC. Osseous repair in infrabony periodontal defects. J Clin
Periodontol 1978; 10(5): 524- 41.
• Caton J, Nyroan S. Histometric evaluation of periodontal surgery. I. The modified
Widman flap procedure. J Clin Periodontol 1980; 7(3):212-23.
• Caton J, Nyman S, Zander H. Histometric evaluation of periodontal surgery.
II.Connective tissue attachment levels after four regenerative procedures. J Clin
Periodontol 1980; 7(3):224-31.
• Melcher AH. On the repair potential of periodontal tissues. J Periodontol 1976;
47(5): 256-60.
• Nyman S, Lindhe J, Karring T, et al. New attachment following surgical treatment
of human periodontal disease. J Clin Periodontol 1982;9(4):290-6.
• Caton JG, DeFuria EL, Poison AM, et al. Periodontal regeneration via selective cell
repopulation. J Periodontol 1987;58(8): 546-52.

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• Nyman S, Gottlow J, Lindhe J, et al. New attachment formation by guided
tissue regeneration. J Periodontal Res 1987;22(3):252-1.
• Wikesjo UM, Crigger M, Nilveus R, et al. Early healing events at the dentin-
connective tissue interface. Light and transmission electron microscopy
observations. J Periodontol 1991;62(1):5-14.
• Wikesjo UM, Nilveus RE, Selvig KA. Significance of early healing events on
periodontal repair: a review. J Periodontol 1992;63(3):158-65.
• Egelberg J. Regeneration and repair of periodontal tissues. J Periodontal
Res 1987;22(3):233- 42.
• McCulloch CA. Basic considerations in periodontal wound healing to
achieve regeneration. Periodontol 2000 1993;l(l):16-25.

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