Dr. Vijeta Vyas PG II Yr.

2. 2
Regeneration is the process of
renewal, restoration and
growth that makes cells and
organisms resilient to natural
fluctuations or events that cause
disturbance
or damage
Regeneration can either be complete or incomplete

3. INTRODUCTION
3
 The Periodontium
consists of cells and
tissue complex organized
into basic components of
cementum, periodontal
ligament and alveolar
bone.
 The challenge of
regeneration is to
reconstitute this complex
onto the root surface.

4. Carranza 10th ed4
PERIODONTAL
INFLAMMATION
PERIODONTAL
THERAPY
LOCAL/SYSTEMIC
TISSUE
RESPONSE
EPITHELIUM
Restore surface
continuity
CONNECTIVE TISSUE
Attach bone to cementum
and establish bone height
BONE
Restore balance between
bone formation and
resorption
CEMENTUM
Attach periodontal fibers

5. PHASES OF HEALING
Lindhe and Lang Clinical Periodontology & Implant Dentistry 6th ed5

6. Healing patterns in the periodontal
tissues
Lindhe 6th6
Healing by first intention Involves the wound edges being
brought together using sutures.
Healing by second intention Occurs in surgical wounds that are
left to heal without approximating the edges.
Healing by third intention wound heal by contraction of wound
edges and In some cases presence of a foreign body or
infection may be suspected.
Partial‐thickness healing Occurs when a partial‐thickness
wound is closed primarily by epithelialization

7. Sources of Regenerating cells
7
A. Gingival Epithelium
B. Connective Tissue
C. Bone Marrow
D. Periodontal Ligament

8. Cells in Periodontal Regeneration
8
• Pericytes
• Endothelial cells
• Platelets
•Macrophages
•Osteoblasts, Osteocytes
•Osteoclasts
• Fibroblasts
• Cementoblasts
•Numerous proteins / growth factors

9. Possible Outcomes Of Periodontal
Therapy
9
Oral epithelium
Bone cells
Periodontal ligament cells
Connective tissue
Karring Et Al 1980
Nyman 1980
Karring 1985

10. TYPES OF HEALING AFTER
PERIODONTAL THERAPY
Carranza 10th ed
10
 Regeneration
 Repair
 New Attachment
 Reattachment
 Epithelial Adaptation
 Bone fill
Sharpey’s Fibers
Bone
PDL
Tooth

11. Regeneration
Carranza 10th ed11
 Regeneration is defined as a 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
(American Academy of Periodontology 1992)
 Regeneration occurs through growth from the same type of
tissue that has been destroyed or from its precursor.

12. 12
 Regeneration of the periodontium is a continuous
physiologic process
It is manifested by :-
(1) Mitotic activity in the epithelium of the gingiva and
the connective tissue of the periodontal ligament
(2) The formation of new bone, and
(3) The continuous deposition of cementum.

13. 13
Repair
 Involves replacement of one tissues with another
tissue, such as fibrous connective tissue, which may
not function as the same as the tissue replaced.
 This process, called “healing by scar”.
 Arrests bone destruction but does not result in gain of
gingival attachment or bone height.

14. 14
 New attachment is the embedding of new periodontal
ligament fibers into new cementum and the attachment
of the gingival epithelium to a tooth surface previously
denuded by disease.
 Reattachment refers to repair in areas of the root not
previously exposed to the pocket, such as after surgical
detachment of the tissues or following traumatic tears
in the cementum, tooth fractures, or the treatment of
periapical lesions.

15. 15
 Epithelial adaptation differs from new attachment in
that it is the close apposition of the gingival epithelium
to the tooth surface, with no gain in height of gingival
fiber attachment.
 Bone fill is defined as the clinical restoration of bone
tissue in a treated periodontal defect

16. Carranza 10th ed,16
PERIODONTAL RECONSTRUCTION
 Refer to the process of regeneration of cells and fibers
and remodeling of the lost periodontal structures that
results in
(1) Gain of attachment level
(2) Formation of new periodontal ligament fibers
(3) A level of alveolar bone significantly coronal to that
present before treatment.

17. Methods to Evaluate Regeneration
17
Clinical methods for evaluation of therapy are
 Periodontal probing – Pocket depth, CAL, Gingival
margin location and width.
 Re-entry procedures
Radiographic evaluation
Histological evaluation
Pretreatment and post treatment are compared to
determine the effect of the therapy.

18. Criteria for regeneration
Bartold PM, McCulloch CA, Narayanan AS and Pitaru S. Tissue engineering: a new paradigm for
periodontal regeneration based on molecular and cell biology. Periodontology 2000 2000; 24:253-269.18
 Functional epithelial seal not more than 2
mm in length.
 New connective tissue fibres must be
inserted into the previously exposed root.
 New acellular extrinsic fiber cementum
must be reformed.
 Alveolar bone height must be restored to
within 2 mm of the CEJ.

19. OBJECTIVES OF REGENERATIVE
THERAPY
19
 Regeneration of new cementum, PDL, and bone as
determined by histologic analysis.
 Bone fill of the osseous defect.
 Clinical attachment gain.
 Pocket elimination.
 Establishment of healthy maintainable environment

20. REQUIREMENTS FOR
PREDICTABLE REGENERATION
20
(1) Thorough Root Planing
(2) Root Biomodification
(3) Space Provision
(4) Preparation Of The Osseous Defects For New
Attachment
(5) Wound Stability
(6) Revascularization
(7) Undisturbed Healing
(8) Flap Management

21. 21

22. Generations in Periodontal
regeneration- Egusa et al., 2012
Egusa H, Sonoyama W, Nishimura M, Atsuta I, Akiyama K. Stem cells in dentistry–Part II:
Clinical applications. Journal of prosthodontic research. 2012;56(4):229-48.22

23. Carranza 13th
23

24. Non–Graft-Associated
Reconstructive Procedures
Carranza 12th
24
 Removal of junctional and pocket
epithelium
- Curettage
- Chemical agents
- Biomodification of root surface
- Surgical Techniques
 Preventing or Impeding the
epithelial migration
 Clot stabilization, wound
protection and space creation
 Orthodontic therapy
 LASER

25. Removal of junctional & Pocket
epithelium
25
 ‘Curettage’ - Removal of granulation tissue from
lateral wall of pocket.
 Unreliable, Regeneration does occur.
 Chemicals - NaS, Phenol, Camphor, Antiformin,
Naocl.
 Effect not limited to epithelium.
 Depth of penetration is not controlled.
 Historical interest.

26. Surgical Techniques
26
 ENAP
- Internal bevel incision
performed.
-Removal of excised tissue
-No elevation of Flap
 Gingivectomy
 Modified Widman Flap
- Elevation of flap
ENAP Gingivectomy

27. Biomodification of root surface
Lindhe 6th
27
Rationale
 To improve blood clot
adhesion
 To expose collagen
fibrils
Methods
 Mechanical
 Chemical
 Combination of the two.
extrinsic collagen fibers
Cementum

28. Citric acid
Carranza 12th
28
• pH 1.0, 2 mins (2-5 mins), ‘Rubbing’ technique
Register & Burdick, 1976
• Removes smear layer
• Demineralisation of root surface on root planed teeth (4μm)
• Eliminate endotoxins and bacteria from the diseased tooth
surface.

29. 29
 Exposes collagen (2-15μm) & collagen splicing
 Exposed and wide dentinal tubules (8.88μm depth)
 Accelerated healing and new cementum formation
occur.
 Prevention of epithelial migration by fibrin linkage (1-3
days) Polson 1984
 Pulpal / epithelial injury

30. Tetracycline
Shewale et al. Root Surface Biomodification: Current Status and a Literature Review on Available
Agents for Periodontal Regeneration ; BJMMR, 2016; 13(2): 1-14,.30
 pH 1.6, 100mg/ml for 2 to 3 mins
Terranova et al., 1986
 Increases fibronectin binding which stimulates
fibroblast attachment and growth.
 Smear layer removal, exposure of dentin tubules /
collagen fibers.
 Endothelial cell growth factor binding to dentin,
stimulating periodontal ligament cell proliferation /
migration.

31. 31
 Adsorbs to enamel and dentin. acts as antimicrobial
local delivery system. Substantivity (50mg/ml - 14
days)
 Collagenolytic enzyme inhibition preventing bone
resorption.
 Prevent epithelial migration
 Recommended for use with biologic mediators

32. EDTA
32
 Higher pH 7.0 to 7.2, 18 to 24% , 2-3mins
 No root resorption and ankylosis
 Chelation
 Surface demineralisation

33. Root Conditioning by Lasers
33
 Lasers are capable of sterilizing the diseased root
surface and thus ultimately promoting cell
reattachment.
Commercially available laser systems
 ER: YAG (Erbium: Yttrium, aluminum and garnet)
 ND: YAG (Neodymium: Yttrium; aluminum and
garnet)
 Carbon dioxide laser

34. CURRENT STATUS
34
 Angelo Mariotti in a systematic review in 2003
concluded that chemical modifiers provides no
additional benefit and clinical significance to
regeneration in patients with chronic periodontitis.
 Systematic review by Karam et al., 2015 - (Citric
acid, lasers)
 Use of root surface modifiers to improve the clinical
outcomes is not justified.

35. Preventing or Impeding the
Epithelial Migration
Carranza 13th
35
Total removal of the interdental papilla covering the defect
and its replacement with a free autogenous graft obtained
from the palate.
 The graft simply delays the epithelium from proliferating
into the healing area.
 This method has not been widely used.
Coronally Displaced Flaps
 increase the distance between the epithelial wound edge
and the healing area.
 suitable for the treatment of mandibular molar furcations
 used mostly in conjunction with citric acid

36. GTR
CARRANZA 13TH
36
 The term Guided tissue
regeneration refers to the
procedures attempting to
regenerate specific anatomical
structures through differential
tissue responses.
 Gottlow.,1986 coined the term
‘GTR’
 Nyman, Gottlow, Lindhe,
Karring., 1982

37. 37
 selective cell repopulation
or controlled tissue
regeneration
 Prevent epithelial migration .
 Maintain space
 Clot stabilization

38. INDICATIONS
38
 Narrow 2 - or 3 - wall defects
 Class II / III (Early)furcations
 Deep craters
 Marginal tissue recession (Class I / II)
 Circumferential defects
 Combined osseous defects
 Ridge augmentation / Guided bone regeneration
 Peri-implant defects

39. Contraindications
39
 Poor oral hygiene
 Class III/IV furcations
 One wall defect
 Lack of motivation
 Horizontal bone loss
 Smoking
 Medical history

40. Generations of GTR Membranes -
Gottlow
40
I II III
Non
Resorbable
Bioresorbable
Bioresorbable with
additional activity
Antimicrobial activity
Bioactivity
Growth factor release

41. Classification of GTR Membranes
41
I. Non-resorbable membranes
a. Cellulose filters
b. Expanded poly tetrafluoroethylene membranes (GORE TEX®)
II. Resorbable materials
a. Collagen membranes
b. Polylactic acid
c. Polyglycolic acid
d. Synthetic liquid polymer Polyglactin
e. Calcium sulfate
f. Acellular dermal allografts
g. Oxidized cellulose mesh

42. Scantlebury’s criteria
42
 Tissue Integration 1982 W.L. Gore & Associates
 Cell Separation 1982, Dr. John Prichard
 Clinically Manageable 1985 Karring and Nyman
 Space Making 1988 Spring
 Biocompatibility Scantlebury, 1993

43. ePTFE Membrane
43
 Fluoropolymer - with carbon and
fluorine bonds
 No enzyme in human body can
cleave C-F bond
 ‘Nodes & fibrils’ microstructure
 Allowed the passage of liquid and
nutritional products through the
barrier, but their microporosity
excluded cell passage .

44. CONFIGURATION
44
Apical border of the
membrane should
extend 3 to 4 mm apical
and laterally 2 to 3 mm
and occlusally should be
placed 2 mm apical to
the CEJ.

45. ADVANTAGES
45
 Inert
 Stable
 Reinforcement
 Longer period

46. DISADVANTAGES
46
 Dehiscence
 Membrane exposure
 Premature membrane removal
 Membrane contamination & colonization

47. Biodegradable Membranes
47
Collagen barriers
 Extracellular macromolecule of the periodontal
connective tissue
 physiologically metabolized
 Chemotactic for fibroblasts
 Hemostatic
 A weak immunogen
 Scaffold for migrating cells

48. Arun K Garg. Bone biology, harvesting, grafting for dental implants. 1st ed. Quint Pub48
Sources - Bovine tendon, bovine dermis, calf skin,
porcine dermis, fish skin, fascia lata, fascia temporalis.
Available in different configurations and sizes.
CollaTape used to cover and stabilize graft materials,
CollaPlug can be placed into or over extraction sockets,
CollaCote can be used to fill in harvested soft tissue
sites, such as the palate
CollaTape
CollaPlug CollaCote

49. 49
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)

50. Polylactic acid
50
 Guidor
 Composed of a blend of polylactic acid softened with
citric acid for malleability and to facilitate clinical
handling.
 Multilayered matrix.

51. 51
 The inner layer-contact with
the bone or tooth, features
small circular perforations
and several space holders
for formation of new
attachment.
 The outer layer- contact
with the gingival tissue, has
larger rectangular
perforations to allow rapid
growth of gingival tissue
into the interspace between
the two layers, preventing or
minimizing epithelial
downgrowth

52. 52
 Studies demonstrated
the efficacy of PLA
membranes for
treatment of
interproximal defects
and gingival recession in
primates, as well as
infrabony defects and
Class II furcation
defects in humans
 Studies also failed to
show adequate
regeneration in
circumferential
periodontal lesions in
primates
It was concluded further modification and transformation were required to create
a membrane that possesses all of the properties necessary to obtain better results

53. PRF
53
 Platelet rich fibrin (PRF) is a totally
autologous blood concentrate system.
 Due to the easy accessibility, minimal
invasivity and time saving.
preparation, the role of PRF-based
matrices gained in importance.
 Direct contact of PRF with
periosteum substantially improves the
blood supply to the keratinized soft
tissue favoring its thickness, as well
as improves blood supply to the
underlying bone tissues.

54. ADVANTAGE
54
 Facilitates blood clot formation.
 Growth factor release kinetics is slow so Regeneration
occur over extended period of time.
 PRF contains leukocytes and macrophages, known cell
types implicated in immunity and host defense.
 Studies found that the use PRF in combination with a
bone-grafting material was superior to either PRF
alone, or bone-grafting material alone.

55. Fate of biodegradable membranes
55
 Collagen -> Collagenase-> Gelatinase->
Oligopeptides->peptidases-> Aminoacids.
 Polylactic acid - 2 stage degradation - Random non
enzymatic cleavage and second loss of mechanical
strength and weight (Pitt et al., 1981)
Free lactic acid - Carbondioxide & Water
 Calcium sulfate - Giant cell reaction
 Amnion & Chorion - autolytic reaction

56. 56
Advantages
 No second surgery
 Chemotaxis of
fibroblasts
 Weak immunogenicity
 Easy manipulation
 Direct effect on bone
formation Augment
tissue thickness
Disadvantages
 Lack of stability
 Poor Space making
 Fast biodegradation

57. Other membranes
57
 Cargile
 Sclera
 Chorion
 Amnion
 Periosteum
 Laminar bone
membranes
 Freeze dried duramater
(Lyodura)
 Oxidised cellulose mesh
 Polglactin 910
membrane (Vicryl
mesh)
 Pericardium
 PRP membrane
 PRF membrane

58. Supporting devices for membranes
58
 Bone grafts
 Tack screws
 Pins
 Frames
 Ti reinforcement

59. Recent advances in membranes
59
• PDGF-BB loaded PLGA membrane (Park et al.,
1998)
•Autologous biological membrane - PRF (Choukron,
2000)
• b-FGF in collagen sponge (Nakahara 2003)
•TGF-b in alginate membrane (Millela et al., 2001)
•rhBMP-2 in nanofiber (Kolambakar et al., 2011)
•Zinc/Calcium loaded membranes (Osorio et al.,
2017)

60. Resorption kinetics of biodegradable
membranes
60
 Bovine tendon collagen 3 - 6 mo
 ADM 4 mo
 PLA/PGA 3 mo
 Porcine dermal collagen 3-4 mo
 Duramater 2-3 mo
 PRF 10-28 days

61. Problems with GTR
61
Membrane exposure
Membrane contamination
Membrane exfoliation
Infection / Abscess formation

62. Evidence on GTR
62
 Systematic review - Sculean et al., 2008 - most
preclinical studies have histologically demonstrated
periodontal regeneration when grafting materials are
combined with barrier membranes.
 Needleman et al., 2006
GTR has a greater effect on probing measures of
periodontal treatment than open flap debridement,
including improved attachment gain, reduced pocket
depth, less increase in gingival recession and more
gain in hard tissue probing at re-entry surgery.

63. 63
Viable tissue transplanted from donor to recipient site
Any biomaterial implanted into osseous defect to
stimulate periodontal regeneration
GRAFT

64. Classification
64
By origin –
 Autograft (Autologous
graft)
 Allograft(Allogenic/
Homologous)
 Xenograft
(Heterogenous)
 Alloplast (Synthetic)

65. 65
By function during
healing
 Osteogenesis
 Osteoinduction
 Osteoconduction
Based on location
 Extraoral grafts
 Intraoral grafts
By composition
 Cortical
 Cancellous
 Cortico-cancellous /
Osteochondral
 Combined hard and soft
tissue graft
By anatomical
placement
 Orthotopic
 Heterotopic

66. Lindhe 6th ed.66
 Osteoproliferative (osteogenetic): new bone is formed
by bone‐forming cells contained in the grafted material.
Autograft
 Osteoconductive: the grafted material does not
contribute to new bone formation per se but serves as a
scaffold for bone formation originating from adjacent
host bone.
Autograft , Allograft
 Osteoinductive: bone formation is induced in the
surrounding soft tissue immediately adjacent to the
grafted material.
Autograft, Allograft, Alloplasts, Xenograft

67. BONE GRAFTING TECHNIQUE
Raymonda . Yukna Svnthetic bone grafts in periodontics67
1. Remove all etiologic factors.
2. Stabilize teeth if necessary
3. Flap design with a plan for closure
4. Degranulation of defect and flap
5. Root preparation
6. Pre-suturing
7. Condense graft materials well
8. Fill to a realistic level.
9. Periodontal dressing.
10. Antibiotic coverage
11. Postsurgical care

68. Schallhorn Criteria For Material
Selection
68
 Biologic acceptability
 Predictability
 Clinical feasibility
 Minimal operative hazards
 Minimal postoperative sequelae
 Patient’s acceptance

69. Bone Grafts and Bone Substitutes
Periodontics Rose and Mealey
69
Bone-Derived Material
Vital Bone Graft
Autograft
Oral- Osseous coagulum
Bone blend
Bone harvested from extraction site, Tuberosity,
Edentulous ridge
Extraoral- Iliac crest

70. 70
Allograft
 Cryopreserved bone
 Fresh bone from iliac crest
Nonvital Bone Graft
 Allografts (human bone)
Freeze-dried bone allograft
Demineralized freeze-dried bone allograft
 Xenograft
Anorganic bovine bone

71. 71
Nonosseous Material
 Organic
Dentin
Cementum
Coral
 Anorganic (alloplasts)
Calcium sulfate (plaster of Paris)
Calcium phosphate-hydroxyapatite
Calcium ceramics
Bioactive glass polymers

72. 72
 In determining what type of graft material to use, the
clinician must consider
 The characteristics of the bony defect to be restored.
 The larger the defect, the greater the amount of
autogenous bone required.
 For small defects and for those with three to four bony
walls still intact, alloplasts may be used alone or with
allografts.
 For relatively large defects or those with only one to
three bony walls intact, autogenous bone must be
added to any other type of graft material

73. Indications & Contraindications
73
 Intrabony defect
 Deep crater
 Class II / III furcation
 Combined osseous defect
 Circumferential defect
 Socket preservation
 Ridge augmentation
 Sinus augmentation
 Subnasal elevation
 Ridge split / expansion
 Periimplant defect
 Non contained defect
 Defect depth < 3mm
 One wall defect
 Shallow crater
 Horizontal bone loss
 Local infection
 Systemic condition

74. Osteogenic Autogenous Bone Grafts
74
 Intraoral sites
 Hegedus 1923,
 Nabers & O’Leary 1965.
 Retain cell viability.
 Gradually resorbs & replaced by viable bone.
 No risk of disease transmission .
 Sources - Healing extraction wounds, Trephined bone,
surgically created wound, maxillary tuberosity,
symphysis, osteoplasty, ostectomy, Ramus.

75. 75
Osseous Coagulum
 Robinson 1969
 Bone dust + Blood
 obtained by carbide bur #6 or #8 at speeds between
5000 and 30,000 rpm
 Advantage- provides additional surface area for the
interaction of cellular and vascular elements on
intraoral bone
 Disadvantages- low predictability and inability to
procure adequate material for large defects
aspiration problems

76. 76
Bone Blend
 Diem 1972
 Plastic like mass
 particle size range from 210 X 105µm
Cancellous bone marrow transplants
 Maxillary tuberosity,
 Extraction sockets 8-12 weeks and apical portion is used as donor
material
Bone swaging
Ewen 1965
 requires an edentulous area adjacent to the defect, from which
the bone is pushed into contact with the root surface without
fracturing the bone at its base

77. 77
Bone From Extraoral Sites
Hegedus 1923
 Iliac crest
 Tibial plateau
 Cranium
ILIAC BONE AND MARROW
Have the most osteogenic and regenerative potential and
one of the two graft materials with reported ability to
regenerate periodontium horizontally or with “zero wall”
defects, meaning actual crestal apposition of bone.

78. 78
 Schallhorn & colleagues(1970)
Treated 182 osseous defects ranging from 3.3-4.2mm in 52
patients with iliac graft Resultant bone fill was 2.6mm in
‘zero or no wall’ defects,3.75mm in one wall defects &
4.16mm in 2 wall defects. Approximately 87% of class II
furcation had complete fill.
 Hiatt & Schallhorn(1971)
Considered the fill of crestal facial and furcation defects to
be more clinically predictable using iliac autografts than
with intraoral cancellous bone.

79. Disadvantage
79
 Second surgical site and
 Possible morbidity associated with these procedures
 Iliac bone and marrow may induce ankylosis and root
resorption, although the reported frequency is 5% or less
(Schallhorn 1972).
 Increased patient expense and difficulty in procuring the
donor material

80. Nature of autograft
80
Cortical graft - Less surface & lining cells
 Most cells undergo necrosis - cytolysis - releases
BMPs
Cancellous graft - More surface cells & lining cells
 Surface cells get nutrition by diffusion
 Only inner osteocytes - necrosis
For augmentation - Cortical
For regeneration - Cancellous
Composite bone graft - Minimum 20% autogenous
graft should be present

81. Allografts
81
 Same species, but different genotype.
Source
 Frozen iliac cancellous bone and marrow,
 Cryopreserved bone from the head of femur
 Freeze-dried bone allograft (FDBA),
 Decalcified FDBA(DFDBA)
 Mechanism - ‘Osteogenic stimulus

82. Bone allografts
82
 Obtained from cortical
bone within 12 hours of
the death of the donor,
defatted, cut in pieces,
washed in absolute
alcohol, and deep-frozen
 sieved to a particle size of
250 to 750 μm, and
freeze-dried.
 Finally, it is vacuum-
sealed in glass vials

83. Drawbacks
83
 Antigenicity
 Risk of disease transfer
 Need for extensive cross matching
All these have precluded the use of frozen iliac allografts in
periodontics

84. Bone biology harvesting grafting84
 FDBA can be used in either a mineralized or a
demineralized (DFDBA) form.
 FDBA may form bone by osteoinduction and
osteoconduction. Because it is mineralized, it
hardens faster than DFDBA.
 FDBA is more effective than DFDBA in the following
situations:
1. Repair and restoration of fenestrations
2. Minor ridge augmentation
3. Fresh extraction sites (used as a fill)
4. Sinus lift cases (used as a graft)
5. Repair of dehiscences and failing implants

85. 85
Demineralised Freeze-dried bone allograft
Marshall Urist 1965
 Induces host mesenchymal cells to differentiate into osteoblasts
 DFDBA are more inductive FDBA
Healing following the use of DFDBA
 Day 1 -Attachment of fibroblasts to ECM.
 Day 5- Cell proliferation and differentiation of chrondroblasts .
 Day 7- chondrocytes with synthesis and secretion of matrix.
 Days 10-12 Vascular invasion, bone formation and
mineralization.
 Day 21, marrow is observed.

86. Xenografts
86
 Bone products from other species
 Calf bone (Boplant) treated by detergent extraction,
sterilized, and freeze-dried.
 Kiel bone is calf or ox bone denatured with 20%
hydrogen peroxide, dried with acetone, and sterilized
with ethylene oxide.

87. 87
 Anorganic bone is ox
bone from which the
organic material has been
extracted by means of
ethylenediamine; it is
then sterilized by
autoclaving
 Yukna et al - 15-amino
acid sequence Collagen I
+ Anorganic bovine bone
(PepGen P-15)

88. 88
Anorganic, bovine-derived bone (Bioss)
 Osteoconductive, porous bone mineral matrix from
bovine cancellous or cortical bone.
 The organic components of the bone are removed, but
the trabecular architecture and porosity are retained.
 The physical features permit clot stabilization and
revascularization to allow for migration of osteoblasts,
leading to osteogenesis.
 Used in combination with GTR for periodontal
regeneration

89. Periodontal surgery cohen89
Advantages
1. Unlimited supply
2. Safe
3. Biocompatible
4. Nonantigenic
5. Permits physiologic vascular
ingrowth
6. Permits complete integration and
incorporation into bone
7. Possesses the same structure as
bone:
a. Compact appetite crystalline
structure
b. Large inner surface area
c. Porosity similar to that of human
cancellous bone

90. Graft-Associated Reconstructive
Procedure of Historical Interest
90
 Sclera
 Dura
 Cartilage
 Cementum
 Dentin
 Plaster of Paris,
 Plastic materials
 Ceramics
 Coral-derived materials

91. Alloplasts
91
 Inert Biologic fillers / Synthetic grafts
 Ceramics and polymers
Ashman’s Criteria (1992)
 Biocompatible Serve as framework
 Resorbable and replaced by bone Osteogenic
 Radiopaque Easy to manipulate
 Not support growth of pathogen Hydrophilic
 Surface electrical activity Microporous
 Non allergenic Act as vehicle
 High compressive strength

92. Classification of Ceramics
92
 Hydroxyapatite (Ca : P = 1.67)
 Calcium phosphate cement
 Calcium sulphate (POP)
 β tricalcium phosphate (Ca : P = 1.5)
 Bioactive glasses
 C-Graft

93. Plastic Materials
93
Hard tissue replacement (HTR) polymer
 Non resorbable
 Micro porous
 Biocompatible composite of polymethylmethacrylate
and polyhydroxyethylmethacrylate
 Histologically, encapsulated by connective tissue
fibers, with no evidence of new attachment

94. Calcium Phosphate Biomaterials
94
 Periograf
 Excellent tissue compatibility
 Osteoconductive
 Two types
Hydroxyapatite (HA) has a Ca:P -1.67
Similar to that found in bone material.
HA is generally nonbioresorbable.
Tricalcium phosphate (TCP) Calcium:P- 1.5
mineralogically B-whitlockite.
Partially bioresorbable.
 Histologically these materials appeared to be
encapsulated by collagen

95. Beta- Tri CalciumPhosphate
95
 Cerasorb
 facilitates incorporation
of new tissue.
 stable and highly
resistant to abrasion.
 a round-particle size of
10 to 63 μm prevents
phagocytosis by
macrophages.
 use as a PRP carrier.

96. Bioactive Glass
Carranza 13th
96
 PerioGlas 90 to 170 μm, BioGran 300 to 355 μm
 Consists of Na and Ca salts, phosphates and silicon
dioxide.
 Bioactive Glass Tissue fluids Particle surface
Hydroxycarbonate apatite Organic ground
proteins( chondroitin sulfate and GAG) attracts
osteoblasts rapidly form bone.
Contacts
coated incorporates

97. COMPOSITE GRAFT
97
 Used most frequently to
increase the advantages
of each product in the
mix and minimize the
disadvantages of each.
 DFBA is added to
previously harvested
autogenous bone to
create a composite graft
mix.

98. Factors for the successful
incorporation
Gordh & Alberius 199998
 Embryonic origin of the graft
 Rate and extent of revascularization
 Structural and biomechanical features
 Rigid fixation of the graft to the recipient site
 Graft orientation and
 Availability of local growth factors.

99. Arun K Garg. Bone biology, harvesting, grafting for dental implants. 1st ed. Quint Pub.99
The higher the osteogenic potential of the defect and of the patient, the smaller the
amount of autogenous bone required and the more allogeneic and alloplastic materials
can be used.

100. Systematic review & Meta analysis
by Chen et al., 2013
100
 GTR only group
 GTR + Bone graft group
 In Class II furcations
Findings
•GTR seemed to be more effective than OFD
•GTR + Bone graft technique showed even better clinical
results

101. RIDGE AUGMENTATION
101
 At times, when teeth are lost due to periodontitis, large
defects in the alveolar bone involving the loss of one
or more socket walls results in defects in ridge
morphology.
 Augmenting and regenerating the deficient alveolar
bone mainly for implant placement and restoring the
lost bone for functional and esthetic purposes

102. Alveolar crest defects
Classification(Siebert)
Class 1 Ridge Defects
when the bone deficiency is
predominantly
in horizontal dimension
Class 2 Ridge Defects
when the bone deficiency
is predominantly
in vertical dimension
Class 3 Ridge Defects
when the bone deficiency
affects both the vertical
and horizontal dimensions
Lindhe 6

103. RIDGE AUGMENTATION
103
 Soft tissue Augmentation
 Hard tissue Augmentation
Horizontal
Vertical
Combined
 Both soft and Hard tissue Augmentation

104. Particulate bone grafting technique
Block grafting approaches
Combination approaches
Ridge expansion/ ridge splitting techniques
Distraction osteogenesis
Bone augmentation approaches using growth factors
TECHNIQUES

105. Critical size defect
105
 Defined as the smallest osseous wound that does not
heal spontaneously over a long period of time.
 Minimum size that renders a defect “critical”
is not well understood.
 It has been defined as a segmental bone deficiency of a
length exceeding 2-2.5 times the diameter of the
affected bone.
 Critical size defect model have been developed to
assess the biologic potential, safety, and efficacy of
new regenerative approaches prior to their use in
humans.

106. Optimal Bone Graft
106
 Particle size - 125μm to 2mm
 Most commercial products 500-1000μm
 Critical minimum value - less than 75 μm to 125 μm is
rapidly resorbed
 125μm to 1000μm - Highest osteogenic potential
 Density = Compressive strength, Porosity = Extent of
vascular ingrowth

107. 107
GRAFT APPROXIMATE RESORPTION TIME
Illiac crest, Tibial plateau, Maxillary
Tuberosity
3-6 mos
Mandibular symphysis 4-8 mos
Bone shavings from adjacent surgical
site
3-7 mos
Bone suctioned while drilling
osteotomies
1-3 mos
FDBA 6-15 mo

108. 108
DFDBA 2-4 mo
POP 1-2 Wks
P-15 18-36 mo
Anorganic bovine bone 15-30 mo
HA 18-36 mo / Non resorbable
b-TCP 4-12 mo / Partial
Coral 5-7 yr
CaSo4 1-2 mo
HTR 10-15 yr / Non resorbable
Perioglass/Biogran 18-24 / 20-22 mo

109. Tissue Engineering With Biologic
Mediators
109

110. Signaling molecules
Kao RT, Murakami S, Beirne OR: The use of biologic mediators and tissue engineering in dentistry.
Periodontol 2000 20:127, 2009110
 Enamel matrix derivative
 Autologous platelet-rich plasma preparations
 recombinant growth factors
recombinant human platelet-derived growth factor-BB
recombinant human basic fibroblast growth factor
 Morphogens
recombinant human bone morphogenetic protein

111. Enamel Matrix Derivative for
Periodontal Regeneration
111
 Harvested from developing porcine teeth
 Contains a mixture of low-molecularweight proteins that
stimulate cell growth and the differentiation of
mesenchymal cells, including osteoblasts.
 Stimulates angiogenesis directly by stimulating endothelial
cell proliferation and chemotaxis, and stimulates VEGF
production by periodontal ligament cells.

112. Platelet-rich plasma
112
Cytoplasmic granules of platelets contains
 Platelet-derived growth factor
 Insulin-like growth factor
 basic fibroblast growth factor-2
 epidermal factor
 vascular endothelial growth factor

113. 113
This mixture of growth factors in PRP stimulates the
 Proliferation of fibroblasts and Pdl cells
 ECM formation
 Neovascularization.
 Suppress cytokine release
 Limit inflammation
 Promoting tissue regeneration

114. Bone morphogenetic proteins
114
 BMP are a group of regulatory glycoproteins that are
members of the transforming growth factor-beta
superfamily.
 BMP 1 to 9, 12, 13, 14
 Urist in 1965 coined the term BMPs or Osteogenetic
protein
 Primarily stimulate differentiation of mesenchymal
stem cells into chondroblasts and osteoblasts.

115. 115
The available sources of BMPs
1) Human or animal bone matrices.
2) Recombinant DNA Technology.
3) Direct site application of DNA encoding for the
desired factor
Carriers
Natural-collagen, hyaluronin, chitosan, gelatin.
Synthetic- polyethelene glycol, polyethelene oxide,
matrix extracts
Non-resorbable- EPTFE, Ceramic, Titanium mesh.
Resorbable- Alpha hydroxyl acids,polyglycolic acids,
poly lactic acid.

116. Role of BMPs in Periodontal
Regeneration
116
 RhBMP-2 has been proved to initiate bone induction process
through many histological studies.
 When rhBMP-2 carrier complex is implanted, mesenchymal
cells which are undifferentiated infiltrate the periphery of
matrix, to degrade the matrix and invade the vascular
endothelium to differentiate into osteoblasts laying bony
trabeculae.
 Later bony trabeculae undergoes physiological remodeling
 Major limitations associated with the use of growth and
differentiation factors are their short biological half-lives

117. Scaffold or supporting matrices
117
Roles
 To provide physical support for the healing area so that
there is no collapse of the surrounding tissue.
 To serve as a barrier to restrict cellular migration.
 To serve as a scaffold for cellular migration and
proliferation.
 To potentially serve as a time-release mechanism for
signaling molecules

118. BIOMATERIALS
118
Allografts
DFDBA, FDBA
Xenografts
Anorganic bovine bone
Alloplasts
Tricalcium phosphate , Hydroxyapatite, Bioactive glass
polymers, Hard-tissue replacement polymer
Polymers and Collagens
Chitosan

119. Gene therapy
119
 Used for extended local delivery of factors.
 Gene delivery of platelet-derived growth factor was
accomplished by the successful transfer of the platelet-
derived growth factor gene into the cementoblast and
other periodontal cell types.
 Stimulates more cementoblast activity.
 Safety and efficacy of using gene therapy for
regeneration have yet to be evaluated

120. Gene therapeutics for tissue
engineering
120

121. 121

122. Combination therapy
122
 An additive effect from combining different
regenerative principles, including
 Osteoconductivity and Osteoinductivity,
 Capacity for space provision
 Blood clot stabilization,
 Ability to induce or accelerate the processes of matrix
formation and cell differentiation that are inherent in
barriers, grafts, and bioactive substances

123. Factors That Influence Therapeutic Success
123
 Selection of the appropriate surgical technique.
 Accurate assessment of the periodontal defect.
 Clinician's clinical experience.
 Importance of the tooth in the overall restorative
treatment plan.
 Patient's selection of the regenerative options.

124. Therapeutic Considerations
124
 Delicate and timely tissue management to minimize
tissue shrinkage
 Passive flap closure for encasement of the graft
materials.
 Flap design to allow tension-free suture placement

125. Tooth and Defect Related
Considerations
125
Tooth's importance in
 Prosthetic rehabilitation
 Endodontic status
 Osseous defect characteristics.
Improved Regenerative results
 Narrow defect > Wide defect
 3/2 wall defect > 1/0 wall defect

126. Patient-Related Considerations
126
After therapy, the difficult challenge is to motivate
patients to be skilled, enthusiastic, and passionate
about their oral hygiene and compliant with
periodontal maintenance.

127. 127
Clinical Guidelines to Guide Clinicians in
Their Patient Management
 Early diagnosis and appropriate addressing of the
defect
 Early narrow intrabony (<3 mm) and furcation defects
can be blended in with the adjacent osseous contour.
 Intrabony and furcation defects of >3 mm, periodontal
regeneration should be considered

128. Conclusion
128
 Regenerative surgical treatment of intrabony periodontal
defects results in dramatic improvements of bone loss, CAL
and PD that cannot be matched by other nonsurgical and
surgical approaches.
 These improvements are maintainable over many years if
appropriate maintenance care is used.
 The combined approach is most useful in large wide
defects where bone grafts supply structural functions,
membranes provide guided tissue and graft retention
functions, and biologic agents give cellular enhancement.

129. 129

130. ALLODERM
130
 Acellular dermal allografts
 Obtained from cadaver skin
 Immunologically inert
 Compatible
 Memory free, easy to place
and adapt, and able to be
covered by soft tissue.
 Unlimited supply, color
match, thickness.
 Formation of additional
attached gingiva

131. 131
 Maintains its collagen, elastin, and proteoglycans,
providing an undamaged acellular dermal matrix.
 At the start of the surgery, the AlloDerm graft is placed
in saline solution for rehydration.
 Once rehydrated it is indistinguishable
 It is important to follow the product’s instructions
carefully to ensure that the correct side of the tissue is
placed.