Gtr and Bone graft

1. GTR &
BONE GRAFTS

2. Bone graft :
Bone or bone like synthetic substance used to
fill a defect in a bone or to augment new
bone formation
Bone Grafts 2

3. Regeneration : Growth and differentiation of new cells and intercellular
substances to form new tissues or parts
Osteoconduction : 3-Dimensional structural scaffold to allow the ingrowth of
capillaries, perivascular tissue and osteoprogenitor cells of the
host into the graft. This process occurs in an already bone
containing environment
Osteoinduction : It involves the stimulation of osteoprogenitor cells to differentiate
into osteoblasts that then begin a new bone formation where
there was no bone. Most widely studied osteoinductive cell
mediators are BONE MORPHOGENIC PROTEINS
Osteogenesis : Refers to the formation of new bone which is contributed by the
vital osteoblasts originating from the bone graft material

4. Classification
Grafts
Bone
Derived
Autogenous Allografts Xenografts
Non Bone
Derived
Alloplast

5. Definitions
Autograft : A graft transferred from one site and grafted to another
site on the same person
Allograft : A graft obtained from a donor of the same species but
with different genetic make up. Formerly called as homograft
Xenograft : A graft between members of different species
[Heterografts]
Alloplast : A synthetic bone graft material ie. A bone graft sustitute
Isograft : A graft between identical individuals

6. Indications of periodontal bone graft
1. Deep intraosseous defect
2. Tooth retention
3. Support for critical teeth
4. Defects associated with
aggressive periodontitis
5. Furcation defects

7. Ideal bone graft should …….
Gross [1997]
1. Be biocompatible
2. Serve as scaffold [framework for new bone formation]
3. Be resorbable in the long term & have the potential
for replacement by host bone
4. Be osteogenic
5. Be radiopaque
6. Be easy to manipulate
7. Non Allergenic
8. Not support the growth of pathogen

8. Ideal bone graft should …….
Gross [1997]
9. Hydrophilic [to attract &
hold the clot in a
particular area]
10.Availability in particulate
& molder forms
11.Microporous
12.Have high compressive
strength
13.Have a surface
amenable to grafting
14.Act as a matrix or
vehicle for other
materials Bone Grafts 8

9. Bone Grafts…….
1. Increase the bone
level
2. Decrease crestal
bone loss
3. Increase CAL
4. Decrease probing
depth
5. Increased CAL &
dereased PD with
GTR
6. Support formation of

10. Disadvantages Of Periodontal Bone Grafting
1. Increased treatment time
2. Longer postoperative treatment
3. Autografts require two sites
4. Increased postoperative care
5. Variability of repair & predictability
6. Need for multistep therapy
7. Expensive
8. Availability of graft material
Bone Grafts 10

11. Necessites For New Bone Growth
1.Presence of blood clot
2.Preservation of osteoblastic
cells
3.Contact with living tissue
Bone Grafts 11

12. Autogenous Bone Grafts

13. Autogenous Bone Grafts
1. Considered the GOLD STANDARD among all the graft materials
2. Gives more predictable results
3. Contains live osteoblasts and osteoprogenitor stem cells and heal
by osteogenesis
AUTOGRAFT
INTRA
ORAL
EXTRA
ORAL

14. Graft Procurement………..
Bone Grafts 14
Bone
Trap
Trephine
Bur
Bone Shaving Suction
Trap

15. Osseous Coagulum
1. Extension of previous
technique
2. Mixture of bone dust
and blood
3. The smaller the particle
size of the donor bone ,
the more certain it’s
resorption and
replacement with host
bone
Bone Grafts 15

16. 4. Sources of the graft
material include the
lingual ridge , exotoses ,
edentulous etc
5. The obvious advantage
is the ease of obtaining
bone from already
exposed surgical sites
6. Disadvantage : Low
predictability and
inability to procure
adequate material for
large defects
Bone Grafts 16

17. Bone Blend
1. Bone is removed from a predetermined site
2. Triturated for about 60 secs
3. Bone blend is seen clinging to the walls
4. Trituration reduces the bone fragment particle size in a
range of about 100 – 200 μm to a workable , plastic like
mass and packed into bony defects
Bone Grafts 17

18. Intraoral Cancellous Bone Marrow
1. Cancellous bone can be obtained
from the maxillary tuberosity ,
edentulous areas and healing
sockets
2. Good amount of foci of red
marrow is observed
3. Healing sockets are allowed to
heal for 8 to 12 weeks and the
apical portion is used as donor
material
Bone Grafts 18

19. Bone Swaging
1. Requires the existence of an edentulous area
adjacent to the defect
2. Bone is then pushed into the defect with the
root surface without fracturing the bone at it’s
base
3. It is technically difficult and it’s usefulness is
limited
Bone Grafts 19

20. Extra Oral Illiac Autografts
1. The use of fresh or
preserved illiac cancellous
marrow has been
extensively investigated
2. Studies show that there
was a mature PDL and
about 2mm supracrestal
new attachment
formation

21. Healing Of Autografts
Four Stages :
• Granulation Stage : When hematoma develops , an inflammatory
response occurs and the formation of granulation tissue takes
place
• Callus Stage : Mesenchymal cell differentiates mainly into
osteoblasts
• Remodelling Stage : Hard callus tissue is replaced by lamella bone
• Modelling Stage : Bone adapts to the structural demands due to
functional stimuli
Bone Grafts 21

22. Autografts ……..
Advantages
1. Promotes osteogenesis
2. Risk of disease transfer
avoided
3. Easily procured
Disadvantages
1. Inadequate material
2. Might need hospitilization
3. Inflicting surgical trauma in
other parts of the body
Bone Grafts 22

23. Allografts
Bone Grafts 23

24. Allografts - An Intro……..
1. They are obtained from
cortical bone within 12 hours
of the death of the donor
2. They are cut into pieces ,
washed in absolute alcohol ,
defatted deep frozen
3. All these radiation , freezing
and chemical treatment was to
suppress the antigenic
potential
24
Bone Grafts

25. Allografts - An Intro……..
4. The material may then
be demineralized and
subsequently ground
and sieved to a
particle size of about
250 to 750 μm and
freeze dried
5. Finally , it is vaccum
sealed in glass vials and
stored in tissue banks
25
Bone Grafts

26. Types
1. Frozen illiac cancellous bone and marrow
2. Mineralized freeze dried bone grafts [FDBA]
3. Decalcified freeze dried bone grafts [DFDBA]
Bone Grafts 26

27. Frozen Illiac Cancellous Bone and Marrow
The possibility of
disease transfer
antigenicity
the need for extensive cross matching
has precluded the use of frozen illiac allografts
in modern periodontics
Bone Grafts 27

28. Mineralized Freeze Dried Bone Allografts [FDBA]
1. Introduction to periodontal therapy in 1976 [Mellonig
et.al ]
2. Freeze drying kills all the cells but
the morphology
the solubility &
chemical integerity of the original
specimen is relatively intact
3. AAP recommends the use of cortical rather than
cancellous bone allografts since cancellous bone is
more antigenic and there is more bone matrix
4. Provides an osteoconductive scaffold
Bone Grafts 28

29. Mineralized Freeze Dried Bone Allografts [FDBA]
Disadvantage :
The potential
disadvantage of
increased turn over
time may
be the bio availability
and
activity of BMP s
because the
mineralized
component must
be resorbed in order
Bone Grafts 29
E.g.: Puros Graft Material

30. Decalcified Freeze Dried Bone Allograft [DFDBA]
1. Demineralization of a cortical bone
induces new bone formation and
greatly enhances it.’s osteogenic
potential
2. Demineralization with HCL exposes
the bone inductive proteins located
in the bone matrix
3. These proteins are collectively called
BONE MORPHOGENIC
PROTEIN [BMP]
Bone Grafts 30

31. 4. BMP stimulates the formation of
new
bone by OSTEOINDUCTION
ie. The demineralized graft induces
host cells to differentiate into
osteoblasts whereas an
undemineralized allograft
functions
by OSTEOCONDUCTION as it
affords a scaffold for new bone
formation
Bone Grafts 31

32. The ideal particle size is
between
250 to 500 μm. This small
size
permits
1. High inductive potential
2. Easy resorption &
replacement
3. Increased surface area for
primordial mesenchymal
interaction
Bone Grafts 32

33. Xenografts
Bone Grafts 33

34. 1. Unlimited supply
2. Safe
3. Biocompatible
4. Nonantigenic
5. Permits vascular ingrowth
6. Permits complete integration & incorporation into
bone
7. Possesses the same structure as bone
a ] compact crystalline structure
b ] large inner surface area
c ] porosity similar to that of human cancellous
bone Bone Grafts 34

35. Xenografts
Calf Bone
[Boplant]
Kiel Bone
Anorganic
Bone
Bone Grafts 35
Treated by
detergent
extraction,steri
lizesd & freeze
dried
Calf or ox bone
denatured with
20% hydrogen
peroxide, dried
with acetone
Ox bone. Organic
material extracted by
means of ethylenediam

36. Alloplasts
Bone Grafts 36

37. Intro ……..
1. Most commonly used bone
substitutes are ceramic
materials
2. Osteoconductive
3. Exihibit good compressive
strength but poor tensile
strength similar to the
property of the bone
4. Available in a variety of
textures , sizes and shapes
5. Does not disturb the bone
base and the ridge is
reconstructed over the
residual bony structure Bone Grafts 37

39. Dense Hydroxyapatite
1. High density
2. More crystalline
3. Osteophillic ,
osteoconductive &
biocompatible fillers
4. slow resorption
5. High compressive
strength but are brittle
6. Not considered for load
bearing conditions
ie. implants
Bone Grafts 39

40. Low Density Hydroxyapatite
1. Amorphous
2. Highly resorbable
3. High calcium source
4. Amount of bone
growth increased
5. A great disadvantage
is that their strength
decreases
exponentially as their
porosity increases
Bone Grafts 40

41. Beta Tri Calcium Phosphate
Cerasorb ;
1. Resorbed & completely
replaced by natural
bone in a period of 3 –
24 months
2. Osteoconductive
3. Highly porous, it is
stable & highly resistant
to abrasion
4. 10 – 63 μm prevents
phagocytosis by
macrophages
Bone Grafts 41

42. HTR [Hard Tissue Replacement Polymer]
1. Biocompatible
microporous composite of
polymethylmethacrylate ,
polyhydroxylethylmethacry
late & calcium hydroxide
2. Resorbs slowly and is
replaced by bone after
approximately 4 – 5 years
3. Bead with CaOH coating
with a central pore of
350μm size
Bone Grafts 42

43. Calcium Sulphate
1. Biologically inert
2. Resorbable in 4 – 8
weeks
3. Grafts composed of
calcium sulphate &
DFDBA used for bone
regeneration
4. E.g. Capset –
this mixture is
adhesive and does’nt
need sutures Bone Grafts 43

44. Osteostimulation - Bioglass
Bioglass particle
,
like table salt

45. Factors Affecting Success Or Failure Of
Regeneration Procedures
1. Plaque control
2. Underlying systemic diseases e.g.
diabetes
3. Adequate wound closure
4. Complete soft tissue approximation
5. Periodontal maintenance
6. Traumatic injury to teeth & tissues
7. Type of graft material
8. Petient’s repair potential
Bone Grafts 45

46. GTR
Bone Grafts 46

47. • “It is a technique of Periodontal treatment
wherein repopulation of Periodontium is
achieved, by guiding the periodontal ligament
progenitor cells to reproduce in the desired
location, by blocking contact of epithelial and
gingival connective tissues with the root using
a barrier membrane during healing.”
Bone Grafts 47

48. Melcher suggests that, under physiological
conditions, only cells from periodontal ligament
can synthesise and secrete cementum to attach
newly-synthesised collagen fibres of periodontal
ligament or lamina propria of gingiva to tooth.
Melcher’s Hypothesis
Melcher AH (May 1976). "On the repair potential of periodontal tissues".
J. Periodontol. 47 (5): 256–60.
48

49. Gingival epithelium-Long JE Gingival connective tissue
Root resorption
Bone-
Ankylosis
PDL cells-
New attachment
49

50. GRADE II FURCATION DEFECTS
ALONE OR COMBINED WITH BONE GRAFTS
50

51. INDICATIONS
TWO & THREE WALLED VERTICAL DEFECTS
51

52. GTR IS MORE PREDICTABLE
IN NARROW DEFECT ANGLE
AND THREE WALLED DEFECTS
52

53. INTER PROXIMAL & CIRCUMFERENTIAL DEFECTS
53

54. GINGIVAL RECESSION
54

55. INDICATIONS
LOCALIZED RIDGE AUGMENTATION
55

56. INDICATIONS
PRE-IMPLANT & PERI-IMPLANT BONE DEFECTS
56

57. 1. REGENERATIVE MEMBRANE SHOULD NOT BE PLACED
WHERE ACTIVE INFECTION EXISTS.
2. DEFECTS WITH SEVERE HORIZONTAL BONE LOSS.
3. DEFECTS THAT DO NOT ALLOW FOR CREATION AND
MAINTENANCE OF SPACE.
4. AREAS WITH INADEQUATE GINGIVA WHERE FLAP
CAN BECOME STRETCHED AND TENSED.
5. IN CASE OF FAILING ENDOSSEOUS IMPLANTS.
6. TO THOSE WHO ARE ALLERGIC TO GTR MATERIAL.
7. NON COMPLIANT PATIENTS.
57

58. IDEAL PROPERTIES FOR A GTR
MATERIAL
1. SAFETY
The materials must be bio-compatible.
Be non toxic, non antigenic & induce little or no inflammation.
2. EFFICACY
# A device should have a specific design for each clinical
application based on a biologic rationale.
# The barrier function must be established and maintained
long enough for tissue guidance.
58

59. IDEAL PROPERTIES
3. TISSUE INTEGERATION
The product should be integrated with the Periodontal tissues
in order to eliminate or reduce epithelial down growth.
4. CELL OCCLUSIVE
It should serve as a barrier to prevent epithelial cells and
at the same time permit selective Repopulation of wound
surface by PDL cells.
5.SPACE MAINTENANCE
It appears that the space defined and protected by the
membrane determined the volume of bone that could be
Regenerated.
59

60. IDEAL PROPERTIES
6. CLINICALLY MANAGEABLE
The properties of the membrane should permit easy
manipulation on the chair side.
7. COST-EFFECTIVE
Should be less expensive and affordable.
8. BIO-ABSORBABLE
The membrane should preferably be Bio-absorbable.
60

61. FIRST GENERATION – Non absorbable
SECOND GENERATION - Absorbable
THIRD GENERATION - GTR membranes
incorporated with
Growth factors,
antibiotics,
adhesion factors etc
61

62. FIRST GENERATION-NON RESORBABLE
1. MILLIPORE (Cellulose) FILTERS
2. ePTFE (GORE TEX®)
3. DENSE PTFE (Tefgen®)
4. Ti- ePTFE (GORE TEX®)
62

63. SECOND GENERATION-RESORBABLE
NATURAL ORIGIN
1.COLLAGEN OF PORCINE ORIGIN (BIO-GUIDE)®
2.COLLAGEN DERIVED FROM
BOVINE ACHILLES TENDON (BIO-MEND)®,(PERIOGEN)®
3.COLLAGEN DERIVED FROM
BOVINE CORIUM (AVITENE)®, (NEO-MEM)™
4.COLLAGEN FROM OX PERITONEUM (CARGILE MEMBRANES)
5.COLLAGEN OF FISH ORIGIN (PERIOCOL-GTR)®
6.OXIDIZED CELLULOSE MEMBRANE (SURGICEL)®
7.ALLODERM ALLOGENIC SKIN MATRIX
8. DURAMATER
63

64. SECOND GENERATION-RESORBABLE
SYNTHETIC
1. GUIDOR® - Poly-DL-lactide
2. VICRYL PERIODONTAL MESH -Polyglactin 910
3. EPIGUIDE ® - Polylactic acid
4. RESOLUTE® - Poly-DL-lactid
5. MEMPOL® - Polydioxanon
6. ATRISORB® - Poly-DL-lactid
7. INION™ - Carbonate
64

65. THIRD GENERATION GTR MEMBRANES
 Atrisorb-D® Free flowTM
 Haemostatic collagen material (Collistat®)
 Collagen membrane enriched with
chondroitin-sulphate (PAROGUIDE®)
65

66. NON ABSORBABLE ABSORBABLE
NEEDS SECOND SURGERY NO NEED FOR SECOND SURGERY
PATIENT DISCOMFORT PATIENT COMFORT
MORE CHAIRSIDE TIME LESS CHAIRSIDE TIME
EXPENSIVE LESS EXPENSIVE
IN CASSE OF INFECTION-
REMOVAL IS EASY
IN CASE OF INFECTION-
REMOVAL NOT POSSIBLE
66

67. COLLAGEN GTR MEMBRANES
67

68. PERIOCOL GTR ALLODERM
68

69. COMMERCIALLY AVAILABLE POLYMER BARRIERS
69

70. GUIDOR® RESOLUTE® VICRYL PERIODONTAL MESH
DOUBLE LAYERED MADE OF POLYLACTIC
ACID & A
CITRIC ACID ESTER
OCCLUSIVE PART OF GLYCOLIDE & LACTIC
COPOLYMER AND A POROUS WEB OF
POLYGLYCOLIDE FIBER
CONSISTS OF POLYGLACTIN 910
EXTERNAL LAYER HAS RECTANGULAR
PERFORATIONS- PROMOTES TISSUE
INTEGRATION
OCCLUSIVE PART PREVENTS CELL INGROWTH FORMS A TIGHTLY WOVEN MESH.
INTERNAL LAYER HAS SMALL CIRCULAR
PERFORATIONS & OUTER SPACERS
POROUS PART PROMOTES TISSUE INTEGRATION
RESORBS IN 6-12 MONTHS.
DEGRADATION BY FOREIGN BODY
REACTION BY MACROPHAGES
RESORBS IN 4 WEEKS BUT COMPLETE
BIOABSORPTION MAY TAKE 5-6 MONTHS
LOSES ITS INTEGRITY IAFTER 2 WEEKS
AND COMPLETELY RESORBS IN 4-6
WEEKS.
CLINICAL & HISTOLOGICAL STUDIES HAVE
PROVED ITS EFFICACY.
HISTOLOGICAL STUDIES HAS PROVEN ITS
EFFECTIVENESS IN NEW ATTACHMENT
HUMAN TRIALS ARE IMPRESSIVE
70

71. EPIGUIDE® MEMPOL® INION
MADE OF POLYLACTIC ACID
POLYMERS
BILAYERED MEMBRANE
MANUFACTURED FROM
POLYDIOXANON(PDS)
MEMBRANES & TACKS MADE OF L-
LACTIC,D-LACTIC,GLYCOLIC ACID &
TRIMETHYLENE CARBONATE
HAS THREE LAYERS TO STOP AND
KEEP AWAY EPITHELIAL CELLS
FIRST LAYER TOTOTALLY
UNPERMEABLE .HELPS
INTEGRATION OF CONNECTIVE
TISSUE
FULLY RESORBED IN 6-12 MONTHS RESORBS LITTLE EARLIER RESORBS IN 8-12 WEEKS
71

72. GBR GTR
WOUND COMPLETELY COVERED
BY FLAP (CLOSED SYSTEM)
OPEN WOUND SYSTEM
(SULCUS IN COMMUNICATION
WITH ORAL ENVIRONMENT)
STERILE CONDITION
MAINTAINED DURING HEALING
STERILE CONDITION NOT
MAINTAINED
STABILIZATION & SPACE MAKING
EASY
STABILIZATION & SPACE MAKING
DIFFICULT
HIGH PREDICTABILITY LOW PREDICTABILITY
INTENDED FOR OSTEOGENIC CELLS INTENDED FOR PDL CELLS
72

73. 73

74. PRE SURGICAL
1. EXPLAIN PATIENTS ABOUT OBJECTIVE, ADVANTAGES
AND DISADVANTAGES.
2. INSTRUCT IN PATIENT’S ORAL HYGIENE.
3. PROPER SCALING & ROOT PLANING.
4. NO VIGOROUS SUBGINGIVAL INSTRUMENTATION AS
THIS MAY PREDISPOSE TO RECESSION IN
SITES RECEIVING GTR.
5. PREFERABLY PRESURGICAL ANTIBIOTICS.
74

75. FLAP DESIGN
1. AIM AT MAINTAINING MAXIMUM KERATINIZED TISSUE.
2. SULCULAR OR SUBMARGINAL INCISIONS WITH SHORT
VERTICAL INCISIONS AT LINE ANGLES OF TEETH.
3. FULL THICKNESS MUCOPERIOSTEAL FLAP BEYOND MGJ
4. INTERPROXIMAL PAPILLA SHOULD BE MAINTAINED.
5. IF LESION IS DISTAL TO TERMINAL TOOTH, THE DISTAL FLAP
SHOULD RETAIN COMPLETE GINGIVAL COMPARTMENT.
THIS IS ACHIEVED BY MAKING ONE INCISION SLIGHTLY
LINGUAL TO CENTER OF RETROMOLAR PAD.
75

76. POST OPERATIVE
1. PATIENT ADVISED NOT FLOSS TREATED SITES FOR 4 WEEKS.
2. CHX MOUTH WASH 0.12% FOR 2 WEEKS.
3. SYSTEMIC ANTIBIOTICS AND ANALGESICS.
4. NON RESORBABLE SUTURES REMOVED AFTER 2 WEEKS.
5. RECALLED EVERY WEEK.
6. NON ABSORBABLE MEMBRANES SHOULD BE REMOVED
BETWEEN 6-8 WEEKS.
76

77. POST OPERATIVE COMPLICATIONS
MEMBRANE EXPOSURE & INFECTION ARE THE COMMON
COMPLICATIONS AFTER GTR.
PROPER TISSUE MANIPULATION AND CLINICAL TECHNIQUES WITH
APPROPRIATE ANTIBIOTICS CAN REDUCE THESE COMPLICATIONS.
FLAP TENSION & IMPROPER ADAPTATION CAN LEAD TO MEMBRANE
EXPOSURE.
SOME STUDIES SUGGEST TOPICAL APPLICATION OF 25%
METRONIDAZOLE GEL MAY IMPROVE HEALING IN AREAS OF MEMBRANE
EXPOSURE. (Sander et al, J.Dent Res, vol 72, 1992)
ADVISABLE TO REMOVE EXPOSED & INFECTED MEMBRANES AS EARLY AS
POSSIBLE.
IF BIOABSORBABLE MEMBRANES ARE EXPOSED AGGRESSIVE ANTI-
INFECTIVE THERAPY SHOULD BE INITIATED.
77