Dr. Sharashchandra., MDS Professor and HOD

1. REGENERATIVE OSSEOUS SURGERY
Presented by
Dr. Sharashchandra, MDS
Prof and HOD

2. New attachment with periodontal regeneration
is the ideal outcome of therapy because it results
in obliteration of the pocket and reconstruction
of the marginal
periodontium

3. REGENERATION AFTER SCALING, RP, CURETTAGE

4. Evaluation of New attachment and Bone regeneration
can be obtained by :
Clinical methods
Radiographic methods
Surgical re-entry
Histological procedures

5. CLINICAL METHODS
Comparison of pre and post-treatment pocket probing
Gingival findings
Measurements of the defect should be made before
and after treatment from the same exact point within
the defect and with the same angulation of the probe
Grooved acrylic stent

6. RADIOGRAPHIC METHODS
Requires carefully positioning of the film and tube
Substraction radiography have enhanced the
usefulness of radiographic evaluation

7. SURGICAL RE-ENTRY
Gives a good view of the bone crest
TWO DISADVANTAGES :
Unnecessary second operation
Does not show the type of attachment

8. HISTOLOGIC METHODS
The type of attachment can be determined
The exact location of the bottom of the pocket
must be determined prior to the procedure
Notches on the root surface must be used to
indicate this important point
Bottom of the pocket is a better land mark

9. REGENERATIVE SURGICAL TECHNIQUES
1.NON-GRAFT ASSOCIATED NEW ATTACHMENT
2.GRAFT - ASSOCIATED NEW ATTACHMENT
All the techniques include careful and
complete removal of all irritants
Trauma from occlusion-- impair healing
reducing the likelihood of new attachment
So - occlusal adjustment - if needed - indicated

10. 1. Non-graft associated New attachment
Periodontal reconstruction can be attained
without the use of grafts in meticulously treated
three-wall defects and periodontal abscess
Removal of junctional and pocket epithelium
methods include :
-- Curettage
-- Chemical agents
-- Ultrasonic methods
-- Surgical techniques

11. CURETTAGE
Not a reliable procedure
Ultrasonic methods and rotary abrasive stones
have been used
Disadvantages :
Effects of the instruments cannot be controlled

12. CHEMICALAGENTS
Sodium sulfide
Phenol camphor
Anti - formin
Sodium hypochlorite
Disadvantages :
Depth of action cannot be controlled

13. SURGICAL TECHNIQUES
Excisional new attachment procedure consists of an
internal bevel incision performed with a surgical knife,
followed by removal of the excised tissue
No attempt is made to elevate a flap
After careful scaling and root planing,inter proximal
sutures are placed

14. PREVENTION OF EPITHELIAL MIGRATION
GUIDED TISSUE REGENERATION
Prevents migration of epithelial cells along the
cemental wall and into the
wound
Favors repopulation of the area by PDL and
the bone
cells
Consists of placing barriers to cover the bone
and periodontal ligament

15. Expanded polytetra flouro-ethylene membrane
can be obtained in different shapes and sizes
ePTFE is also called as GORE-TEX membrane

16. TECHNIQUE
1. Raise a mucoperiosteal flap with vertical
incisions extending a minimum of two teeth
anteriorly and one tooth distally to the tooth
being treated
2. Debride the osseous defect and thoroughly
plane the roots

17. 3. Trim the membrane with sharp scissors to
the approximate size of the area being treated
-- The apical border of the material should
extend 3-4mm apical to the margin of the defect
and laterally 2-3mm beyond the defect
-- The occlusal border of the membrane
should be placed 2mm apical to the CEJ
4. Suture the membrane tightly around the tooth
with a sling suture

18. 5. Suture the flap back in its original position
or slightly coronal using independent sutures
-- Flap should cover the membrane completely
6. The use of periodontal dressings is optional
Patient is placed on antibiotic therapy for 1week
After 4 - 6 weeks the margin of the membrane
becomes exposed
The membrane is removed with a gentle tug
6 weeks after the operation

19. GUIDED TISSUE REGENERATION
AFTER 2 yrs

20. Pre-operative view –max 2nd molar_ radiographic pointer_deep,distal vertical bone loss
Autogenous bone placed in the defect_ Bioresorbable membrane placed over graft
Sutures placed postoperative – 6months

21. CORONAL PLACEMENT OF FLAP

22. BIO-MODIFICATION OF THE ROOT SURFACE
Changes in the root surface wall of periodontal
pocket [e.g degeneration of sharpey’s fibers, accumulation
of bacteria and their products and disintegration of
cementum and dentin] interfere with New attachment
These obstacles to New attachment can be
eliminated through root planing

23. Substances used to better the condition of the
root surface for attachment of new connective
tissue fibers include
-- citric acid
-- fibronectin
-- tetracycline

24. CITRIC ACID
ACTIONS
Accelerate healing & new cementum formation
Produces a 4mm deep de-mineralized zone
with exposed collagen fibers
Removes the smear layer exposing the
dentinal tubules and also makes the tubules
appear wider
Eliminate endotoxins and bacteria from the
diseased tooth surface
Prevents the epithelium from migrating
over treated roots

25. TECHNIQUE
1. Raise a mucoperiosteal flap
2. Thoroughly instrument the root surface
removing calculus and underlying cementum
3. Apply cotton pledgets soaked in a saturated
solution of citric acid [PH 1] and leave on to 2-5mnts
4. Remove pledgets and irrigate root surface
profusely with water
5. Replace the flap and suture

26. GROWTH FACTORS
Secreted by -- macrophages
-- endothelial cells
-- fibroblasts
-- platelets
Include -- platelet derived growth factor
-- insulin-like growth factor
-- fibroblastic growth factor
-- transforming growth factor
Used -- periodontal wound healing

27. 2. GRAFT MATERIALS
Bone graft materials are evaluated based on
-- Osteogenic
-- Osteoinductive
-- Osteoconductive potential

28. Osteogenesis
Formation of new bone by cells contained in the graft
Osteoinduction
Chemical process by which molecules contained
in the graft convert the neighboring cells into
osteoblasts, which in turn form bone
Osteoconduction
Physical effect by which the matrix of the graft
forms a scaffold that favors outside cells to
penetrate the graft and form new cells

29. Selection of a material is based on
Biological acceptability
Predictability
Clinical feasibility
Minimal operative hazards
Minimal post-operative sequelae
Patient acceptance

30. AUTOGENOUS BONE GRAFTS
BONE FROM INTRAORAL SITES
Osseous coagulum
Bone blend
Bone swaging

31. OSSEOUS COAGULUM
Mixture of bone dust and blood

32. BONE BLEND
Technique uses an autoclaved plastic capsule
and pestle
Bone is removed from a predetermined site
triturated in the capsule to a workable plastic
like mass and packed into bony defects

33. AUTOGENOUS BONE GRAFTING

35. Bone particles obtained by use of back-action chisel

36. TREPHINE USED FOR OBTAINING BONE_ FRONTAL VIEW OF TRPHINE
DONAR SITE __ PLACED IN DAPPEN DISH

37. BONE SWAGING
Requires the existence of 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

38. BONE FROM EXTRAORAL SITES
Allografts
Xenografts
Non-bone graft materials

39. ALLOGRAFTS
undecalcified freeze-dried bone allograft [FDBA ]
Decalcified freeze-dried bone allografts

43. XENOGRAFTS
Calf bone : treated by detergent extraction,
sterilized, and freeze-dried, has been used for the
treatment of osseous defects
Keil bone : is calf bone or ox bone denatured
with 20% hydrogen peroxide,dried with acetone,
and sterilized with ethylene oxide
All these materials have been tried and discarded

44. NON BONE GRAFT MATERIALS
Sclera
Cartilage
Plaster of paris
Calcium phosphate bio-materials
eg: Hydroxyapetite[HA]--Non-bioresorbable

45. SCLERA
HYDROXYAPATITE

46. FACTORS INFLUENCING SUCCESSFUL OUTCOME
THERAPIST CONSIDERATIONS - training
- experience
PATIENT FACTORS - systemic conditions
- stress level
- smoking
- plaque control
- tissue response

47. DEFECT FACTORS - bone height
SURGICAL CONSIDERATIONS
- flap design
- root preparation
- bio-modification
- regenerative materials used
- infection control
- post-surgical management and
- supportive periodontal therapy
after completion of active therapy