Clinical concepts for regenerative periodontology

1. Clinical Concepts for Regenerative
therapy in Intrabony Defects
PIERPAOLO CORTELLINI &
MAURIZIO S. TONETTI
Periodontology 2000, Vol. 68, 2015, 282–307

2. • PERIODONTITIS
• REGENERATION
(American Academy of Periodontology)
• GUIDED TISSUE REGENERATION
(A.H.Melcher1976)

3. Aims of the review
• To review the current scientific literature highlighting the
strengths and weaknesses of periodontal-regenerative
approaches in intrabony defects
• To discuss the patient, defect and surgery-associated
factors.
• To propose a step-by step clinical approach in order to
build up a scientifically sound strategy to optimize the
clinical outcomes

4. Evidence for clinical efficacy and
effectiveness
• Efficacy : relates to the added benefit of a
treatment modality under ideal experimental
conditions
• Effectiveness: relates to the benefit that can be
achieved, in relation to morbidity and adverse events,
in a regular clinical setting

5. • 2002, 2003 and 2008
• European Workshop on
Periodontology
( European Federation of Periodontology)
• Workshop on Emerging
Technologies in Periodontics
(American Academy of Periodontology)

6. • Barrier membranes (Guided tissue
regeneration)
• Bone-replacement graft materials
• Biologically active regenerative materials
• Combinations

7. Clinical efficacy of barrier
membranes
 Systematic reviews and meta-analyses
Murphy & Gunsolley (2003)
Needleman et al (2006)
 Prospective multicenter studies
Cortellini P et al(2001)
Tonetti M et al (1998)

8. Efficacy of bone-replacement graft
materials
 Systematic reviews
Trombelli et al (2002)
Reynolds et al (2003)

9. Clinical efficacy of biologically
active regenerative materials
• Meta-analyses only enamel matrix
derivative
• Trombelli et al(2002)
• Giannobile et al(2003)
• Esposito et al (2005,2009)

10. Combination therapy
• Meta-analyses.
Trombelli & Farina (2008)
Tu et al(2010)
• Systemic Review
Espisito etal(2009)
Sanz etal(2005)

11. PATIENT FACTORS
• CONTROL OF PERIODONTITIS
Ehmke et al(2003)
Heitz-Mayfield et al(2006)
• CIGARETTE SMOKING
Tonetti et al(1995)

12. DEFECT PROGNOSTIC FACTORS
1) DEPTH OF THE DEFECT
Tonetti et al (1993,1996)
Cortellini et al(1998)
2) WIDTH OF THE DEFECT(angle ≤25◦-≥37◦)
Steffenson and Weber (1989)
Cortellini and Tonetti (1999)

13. 3) NUMBER OF RESIDUAL BONY WALLS
Gold H cohen (1958)
Schallhorn (1970)
Tonetti (1993,1996,1998,2004,2006)
4) ENDODONTIC STATUS OF THE TOOTH
Cortellini and Tonetti (2000)
5) TOOTH MOBILITY
Sanders et al (1993)
Miller SC (1943)

14. SURGERY-ASSOCIATED FACTORS
• Presence of space for the formation of the
blood clot
• Stability of the blood clot
• Soft-tissue protection of the treated area

15. Materials for regenerative surgery
• Barrier membranes
• Grafts
• Biological active regenerative materials
• Combinations

16. Barrier membranes
• Mechanically select the cells able to
repopulate the blood clot Polimeni (2006)
• Provide space
• Increase blood clot stability.

17. Bone-replacement graft materials
• Osteoconductivity and osteo-inductivity
• Capacity for space provision and blood-clot
stabilization
• Rosen PS et al(2000), Trombelli(2008)
• Bower GM et al(1989)

18. Biologic products/compounds
Bosshardt et al(2008)
• Based on their ability to induce or accelerate
the processes of matrix formation and cell
differentiation

19. SURGICAL APPROACH
PAPILLA PRESERVATION FLAPS
≤2mm
SIMPLIFIED PAPILLA
PRESERVATION FLAP
(Cortellini et al 1999)
>2mm
MODIFIED PAPILLA
PRESERVATION FLAP
(Cortellini et al 1995)

20. AIM
• To achieve and maintain primary closure of
the flap
• To increase the ability to create space for
regeneration in the interdental area

21. MODIFIED PAPILLA PRESERVATION FLAP WITH
ePTFE

22. SIMPLIFIED PAPILLA PRESERVATION FLAP WITH
BIORESORABLE MEMBRANE

23. MICROSURGICAL APPROACH
Cortellini & Tonetti (2001 , 2005) and Wachtel et al (2003)
• Use of operative microscopes and microsurgical
instruments to increase visual acuity and surgical
accuracy .
• Microsurgery reduced wound failure to a mere 6% of
the treated sites.

24. MINIMALLY INVASIVE SURGICAL
TECHNIQUE
(Harrel & Rees 1995)
AIM
• To produce minimal wound
• Minimal flap reflection
• Gentle handling of the soft and hard tissues

25. TECHNIQUE
• Simplified papilla preservation flap and
Modified papilla preservation technique .
• Minimal extension of incision and reflection of
flap.
• Periosteal incisions are never performed
• Single internal modified mattress suture.
• Operating microscope or magnifying loops at
4–16× magnifications
• Microsurgical instruments

26. MINIMALLY INVASIVE SURGICAL TECHNIQUE WITH
SIMPLIFIED PAPILLA PRESERVATION FLAP

27. MODIFIED MINIMALLY INVASIVE SURGICAL
TECHNIQUE
• Cortellini P and Tonetti MS(2009)
• Specifically to improve flap stability
• To provide self-ability to maintain space for
regeneration.
• Treatment in conjuction with biologically
active agent

28. TECHNIQUE
• Tiny interdental access in which only a buccal
triangular flap is elevated.
• The papilla is left in place, connected to the root
of the crest-associated tooth with its supracrestal
fibres.
• Access to the defect is gained through the tiny
buccal triangular flap.
• The supracrestal fibres of the defect-associated
papilla and the palatal tissues are left untouched.
• The minimal wound and the minimal flap
elevation allows for preservation of blood supply
to the interdental tissues.

29. MODIFIED MINIMALLY INVASIVE SURGICAL
TECHNIQUE

30. SURGICAL AND POSTSURGICAL EVENTS
• Chair-time required for the surgical procedure.
• Postsurgical complications.
• Pain and painkiller consumption after the
procedure.

31. Referenc
-es
Regenerative approach No.
of
Pts.
Chair
time
(min)
Subjects
with
postopera
tive
pain (%)
Pain
intensity
No. of
Pain-
killers
Cortellini
et al.
2001
Simplified papilla
preservation flap/modified
papilla preservation technique
+ bioresorbable barriers
56 99±46 46 28.1 ± 2.5 4.1± 2.5
Tonetti
et al.
2004
Simplified papilla
preservation flap/modified
papilla preservation technique+
amelogenins
83 80±34 50 28.0 ± 20.0 4.3 ± 4.5
Cortellini
&Tonetti
2007
Minimally invasive surgical
technique + amelogenins
40 58±11 30 19.0 ± 10.0 1.1 ±2.0

32. CLINICAL POTENTIALAND LIMITS FOR
REGENERATION
Cortellini et al(2008), Ribairo et al (2011)
• Regeneration seems to express its potential as
much as the ‘container’ allows it to do so and
irrespective of the ‘regenerative approach Cortellini
et al (2011)
• Regenerative therapy can be successfully applied,
even at hopeless teeth, and has the potential to change
their prognosis.

35. Clinical strategies
• Trombelli et al(2002), Murphy &
Gunsolley(2003), Giannobile &
Somerman(2003), Esposito et al(2005)(2009),
Needleman et al(2006)
• Regenerative approaches failed to
demonstrate clear superiority of one of the
tested materials.

36. PATIENT
FACTORS
Local factors
Plaque FMPS <15% Smoke >10 daily
Behavioural factors
stress
Systemic factors
Infection FMBS<15% Complaince Disease(diabetes)
Control factors

37. PRESURGICAL
CONDITIONS
ENDODONTIC
CONDITIONS
LOCAL
CONTAMINATION
DENTAL MOBILITY
VITAL NONVITAL
ENDO
TREATED
BOP + BOP -
DEGREE
I
DEGREE
II
DEGREE
III
DEFECT NOT
INVOLVING
APEX
DEFECT
INVOLVING
APEX
NOT
PROPERLY
PROPERLY
ROOT
PLANING+
LOCAL AB
NO LOCAL
TREATMENT
NO
SPLINT
SPLINT
NO ENDO ENDO NO ENDO

42. Long-term effects and benefits of
regeneration
Stability of sites treated with guided tissue
regeneration (Cortellini et al1994)
• Patients’ participation
• Absence of bacterial plaque
• Absence of bleeding on probing
• Reinfection with periodontal pathogens in the
treated sites

43. CONCLUSIONS
The adoption of a clinical strategy for optimal
application of materials and surgical approach
could increase the efficacy of periodontal
regeneration and provide improved clinical
outcomes

44. THANK YOU