2. CONTENT
Introduction
Non Bone graft associated procedures
Biomodification of the root surface
Guided tissue regeneration
Biologic mediators (growth factors)
3. INTRODUCTION
GOALS OF PERIODONTAL THERAPY have long included
Arresting the disease process,
Preventing disease recurrence
Regenerating periodontium lost as a result of periodontal
disease.
4. POSSIBLE OUTCOME OF THE
PERIODONTAL
THERAPY
1. Healing with long junctional epithelium
2. Ankylosis of the bone and tooth
3. Recurrence of the Pocket
4. New attachment with new PDL inserted into
new bone &
new cementum
5. Any combination of above
5. AFTER THERAPY, THE CLOT FORMED IS
INVADED BY CELLSFROM
A: THE MARGINAL EPITHELIUM
B: THE GINGIVAL CONNECTIVE TISSUE
C: THE BONE MARROW
D: THE PERIODONTAL LIGAMEN
SOURCES OF REGENERATING CELLS IN THE HEALING STAGES
OF PERIODONTAL POCKET.
6. NON BONE GRAFT ASSOCIATED
PROCEDURES
Removal of the junctional and pocket epithelium
Guided tissue regeneration
Biomodification of the root surface
Biologic mediators (growth factors)
7. REMOVAL OF THE JUNCTIONAL AND
POCKET EPITHELIUM
The presence of junctional and pocket epithelium has
been perceived as a barrier to successful therapy.
Methods:
Curettage
Chemical agents
Ultrasonics
Surgical techniques.
8. A. Surgical removal by curettage
Results of removal of epithelium by means of curettage vary
from complete removal to persistence of as much as 50%.
therefore is not a reliable procedure.
9. CHEMICAL AGENTS
The most commonly used drugs have been
sodium sulfide,
phenol camphor,
antiformin,
Sodium hypochlorite.
Disadvantage
However, the effect of these agents is not limited to the epithelium, and their
depth of action cannot he controlled. They are mentioned here for their
historical interest.
11. Internal bevel incision
Remove the excised tissue with a curette
Perform rootplaning
Approximate the wound edge
EXCISIONAL NEW ATTACHMENT PROCEDURE
12. MODIFIED WIDMAN FLAP
Glickman and Prichard have advocated performing a gingivectomy to the
crest of the alveolar bone and debriding the defect.
GINGIVECTOMY
• The modified Widman flap, as described by Ramfjord and Nissle, is similar
to the excisional new attachment procedure but is followed by elevation of a
flap for better exposure of the area It eliminates the pocket epithelium with the
internal bevel incision
13. GUIDED TISSUE REGENERATION
Method for the prevention of epithelial migration along the cemental wall of
the pocket and maintaining space for clot stabilization is a technique called
guided tissue regeneration (GTR).
This method is derived from the classic studies of Nyman, Lindhe, Karring,
and Gottlow .
14. GTR consists of placing barriers of different types (membranes) to cover the
bone and periodontal ligament, thus temporarily separating them from the
gingival epithelium and connective tissue.
The initial membranes developed were nonresorbable.
This second operation was done after, usually 3 to 6 weeks after the first
intervention.
16. Studies by Gottlow & Cortenelli indicate that e-PTFE may support significant
amounts of periodontal regeneration( up to 6.8mm) in intrabony defects in
histological sections at 3-6 months healing interval.
Pontoriero et al reported results in grade II furcations treated with EPTFE 90%
showed complete resolution as compared to only 20% in control group.
Studies using e-PTFE show a bone fill of 3.0mm to 5.0mm with / without graft
material in intrabony defects, with 3-walled defects responding the best.
18. The ePTFE membrane (nonresorbable) can be obtained in different
shapes and sizes to suit proximal spaces and facial/lingual surfaces of furcations
19. TECHNIQUE
Raise a mucoperiosteal flap with vertical incisions, extending a
minimum of two teeth anteriorly and one tooth distally to the tooth
being treated.
Apical border of the material should extend 3 to 4 mm apical to the
margin of the defect ,
Laterally 2 to 3 mm beyond the defect,
23. REMOVAL OF MEMBRANE
The initial membranes developed were nonresorbable and
required a second surgical procedure to remove them.
This second procedure was accomplished after the initial
stages of healing, usually 4 to 6 weeks after the first
intervention.
27. CITRIC ACID
Accelerated healing and new cementum formation occur after
surgical detachment of the gingival tissues.
Root-planed, citric acid application not only removes the smear
layer, exposing the dentinal tubules, but also makes the tubules
appear wider and with funnel-shaped orifices.
An early fibrin linkage to collagen fibers exposed by the citric acid
treatment prevents the epithelium from migrating over treated
roots.
28. Recommended citric acid technique is as
follows:
Raise a mucoperiosteal flap and thoroughly instrument the root surface,
removing calculus and underlying cementum.
Apply cotton pledgets soaked in a saturated solution of 10% citric acid
(pH of 1.0) for 2 to 5 minutes.
Remove pledgets, and irrigate root surface profusely with water.
Replace the flap and suture.
29. FIBRONECTIN
Fibronectin is the glycoprotein that fibroblasts require to attach to root
surfaces. The addition of fibronectin to the root surface may promote new
attachment.
This material is commercially available as Tissucol . It is a biologic mediator
that enhances the tissue response in the early phases of wound healing,
prevents separation of the flap, and favors hemostasis and connective tissue
regeneration.
30. TETRACYCLINE
In vitro treatment of the dentin surfaces with 25% tetracycline.
It also removes an amorphous surface layer and exposes the dentin
tubules.
A human study showed a trend for greater connective tissue
attachment after tetracycline treatment of roots.
31. New connective tissue attachment following citric acid demineralization
of root surfaces has been demonstrated histologically in humans (Cole et
al. 1980)
Results from clinical trials indicate no additional improvement in clinical
conditions when citric acid treatment is used in conjunction with surgical
procedures, either without(Kersten BG1992, Moore JA 1987) or in
combination with osseous grafts (Renvert S 1985) or GTR techniques
32. ENAMEL MATRIX PROTEINS
Biomodification of root surface with enamel matrix protein during
surgery ,following demineralization with EDTA has been introduced.
Based on the biological concept that the application of enamel matrix
protein may promote periodontal regeneration as it mimics events that
takes place during the development of periodontal tissues.
33. TECHNIQUE
Described by Mellonig.
Raise a flap for reconstructive purposes
Remove all granulation tissue and tissue tags, the root surface should
be thoroughly planed.
Completely control bleeding within the defect.
Demineralize the root surface with citric acid (pH of 1.0), or preferably
with 24% ethylenediaminetetraacetic acid (EDTA Biora) (pH of 6.7) for
15seconds. This removes the smear layer and facilitates adherence of
the Emdogain.
34.
35. LASER
Low-level lasers (LLLs) work in the milliwatt range with wavelengths usually
in the red or near-infrared spectrum (500–900 nm) without inducing
thermal effects.
Laser-enhanced biostimulation has been reported to induce intracellular
metabolic changes, resulting in faster cell division, proliferation rate,
migration of fibroblasts and rapid matrix production.
In particular, the results obtained in Kreisler’s study (2003) revealed that an
809-nm LLL light had a stimulatory effect on the proliferation of PDL
fibroblasts.
36. BIOLOGIC MEDIATORS
Attempts with bone Grafting substitutes have resulted in some
regeneration.
One way to stimulate these cells is to use proteins (growth factors) that
can bind to surface receptors on the cell membranes,
37. Effects of growth factors used for
regeneration
Growth Factors Effects
Platelet derived Growth Factor Migration, proliferation and noncollagenous matrix
synthesis is mesenchymal cells
BMP Proliferation, differentiation of osteoblast.
EMD Proliferation, protein synthesis in periodontal
ligament cells, osteoblast and cementoblast
Transforming growth factor-beta Proliferation of cementoblast and periodontal
ligament fibroblast
Insulin-like growth factor 1 Cell migration, proliferation, differentiation and
matrix synthesis
Fibroblast growth factor 2 Proliferation and attachment of endothelial cells
and PDL cells
38. REQUIREMENTS FOR
MULTIPLE GROWTH FACTORS
Wound healing is a complex process that involves several
overlapping stages including inflammation, formation of
granulation tissue, re epithelialization, matrix formation and
remodeling.
This healing cascade is executed and regulated by an equally
complex signaling network that involves numerous GFs,
cytokines and chemokines.
39. A SYSTEMATIC REVIEW OF THE USE OF GROWTH
FACTORS IN HUMAN PERIODONTAL REGENERATION.
(DARBY IB 2013)
To perform a systematic review of human studies using growth factors for
periodontal regeneration and to compare the efficacy of these growth
factors to other accepted techniques for periodontal regeneration.
40. The goals of periodontal therapy include:
the reduction or elimination of tissue inflammation induced by bacterial
plaque and its by-products, correction of defects or anatomical problems
caused by the disease process, and regeneration of lost periodontal
tissues as a consequence of disease destruction.
CONCLUSION
41. Guided tissue regeneration-particularly in 3-wall intrabony and
gingival recession defects.
less predictable, results in treating Class II furcation defects, particularly
those involving mandibular teeth.
42. Root surface modification using demineralization -has shown variably
favorable results that are not reliably reproducible in humans. Hence,
the value of this approach in clinical practice remains limited.
Growth factors and proteins- Histologic evidence demonstrated greater
periodontal regeneration when using growth factors compared to other
regenerative techniques
Establishing a scientifically sound, evidence-based rationale is critical to
the ultimate success of regenerative therapies.
43. 1. Clinical Periodontology – Carranza -11th Edition
2. Text Book Of Clinical Periodontology And Implant Dentistry- J. LINDHE - 5th
EDITION
3. Periodontal surgery-A clinical atlas –Sato.N
4. Color atlas of periodontology. HM Wolf
5. Periodontal Therapy-Clinical Approaches and Evidence of Success- Nevins.M
6. Pellegrini G, Pagni G, Rasperini G. Surgical Approaches Based on Biological
Objectives: GTR versus GBR Techniques. Int J Dent. 2013.
7. Periodontal Regeneration. Position Paper. J Periodontol September 2005
8. Rios HF, Lin Z, Oh B, Park CH, Giannobile WV. Cell- and gene-based therapeutic
strategies for periodontal regenerative medicine. J Periodontol 2011
Sep;82(9):1223-37.
REFERENCES
