This document discusses periodontal regeneration techniques. It defines regeneration as the renewal of tissues through growth and differentiation of new cells. Repair restores continuity but does not result in new attachment. New attachment embeds new periodontal ligament fibers into cementum. Autografts use bone from the patient while allografts use bone from others. Various graft materials, membranes, and biological modifiers are discussed that can enhance periodontal regeneration results. Maintaining good oral hygiene is important for sustaining positive outcomes.

1. By,
R. Vaishnavi
R. Swetha
S.P.Vajitha Begam
Final year, BDS

2. What is Regeneration
Regeneration is the natural renewal of a
structure, produced by growth and
differentiation of new cells and
intercellular substances to form new
tissues or parts

3. Repair:
It restores the continuity of the diseased
marginal gingival and re-establishes a
normal gingival sulcus.
This process heals by scar arrest bone
destruction but doesn’t result in gain of
gingival attachment or bone height.

4. New Attachment
It is the embedding of new periodontal
ligament fibres into new cementum and
attachment of gingival epithelium to a
tooth surface previously denuded by
disease.

8. Autograft
Allograft
Xenograft
Alloplast

9. Osteogenic
Osteoinductive
Osteoconductive
Osteoneutral

10. Fast
resorbin
g
Slow
resorbin
g
Non
resorbing

11. 1. Nontoxic
2. Nonantigenic
3. Resistant to infection
4. Predictability
5. Clinical feasibility
6. Easy adaptability
7. Readily and sufficiently available
8. Minimal operative and postoperative hazards
9. Adequate bone fill and promotion of new
attachment in- cluding cementogenesis
10. Cost effective and acceptable to the patient

12. Types
of
graft
Autogenous
graft
Allogenic
graft
Alloplastic
graft
Xenograft

14. Sources of bone include
 Bone from healing extraction wounds
 Bone from edentulous ridges
 Bone trephined from within the jaw without
damaging the roots
 Bone re- moved from tuberosity or
the ramus
 Bone removed during osteoplasty and
ostectomy

15. Osseous Coagulum
• It is a mixture of bone dust and blood.
• The technique uses small particles ground from
cortical bone.

16. Bone Blend
• To overcome these problems, the "bone blend
technique" has been proposed.
• The 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

18. Bone Swaging
The bone swaging technique 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

19. • The use of fresh or preserved iliac cancellous marrow,
bone has been extensively investigated
• Because of numerous problems associated with its use,
the technique is no longer in use.
• Some of the problems were:
 Postoperative infection
 Bone exfoliation
 Sequestration
 Varying rates of healing
 Root resorption
 Rapid recurrence of the defect
Bone from extraoral site

22. Freeze-Dried Bone Allograft
• It is considered an osteoconductive material.
• FDBA being slow resorbing is often used in
guided bone regeneration.

23. Demineralized Freeze-Dried Bone
Allograft
• It is considered an osteoinductive
graft.
• DFDBA has a higher osteogenic
potential
• Demineralization in cold, diluted
hydrochloric acid exposes the
components of bone matrix, which
are closely associated with collagen
fibrils and have been termed bone
morphogenetic proteins (BMPs)

25. • Calf bone (Boplant), treated by detergent
extraction, sterilized and freeze dried, has been
used for the treatment of osseous defects.
• Kiel bone and anorganic bone derived from ox
were used previously which were discarded.

26. Bio-Oss
• Currently, an anorganic, bovine-derived bone
marketed under the brand name Bio-Oss
(Osteohealth) has been successfully used both
for periodontal defects and in implant surgery.
• It is an osteoconductive,
porous bone mineral matrix
from bovine cancellous or
cortical bone.

29. It includes
 Plaster of Paris
 Ceramics
 Polymers
 Bioactive glasses
 Coral-derived materials

30. Calcium Phosphate Biomaterials
These materials are osteoconductive and, therefore, act as a
scaffold for blood clots to be retained to allow bone formation.
Two types of calcium phosphate ceramics have been used:
 Hydroxyapatite –
o calcium-to-phosphate ratio of 1.67
o Non bioresobable
Tricalcium phosphate-
o calcium-to-phosphate ratio of 1.5
o partially bioresorbable

31. Bioactive Glass
• Bioactive glass consists of sodium and calcium salts,
phosphates, and silicon dioxide
• For its dental applications, it is used in the form of
irregular particles measuring
 90-170 µm (PerioGlas, Block Drug, Jersey City, NJ)
 300-355 µm (BioGran, Ortho Vita, Malvern, PA)

32. Enamel Matrix Derivative
• EMD has been effective in the treatment of
infrabony defects.
• EMD has been shown to be safe for clinical use.
• It was found that radiographic
bone level was restored,
normal clinical attachment
level (CAL) was gained and
pocket depth was reduced.

34. Guided Tissue Regeneration

35. • GTR is used for the prevention of epithelial
migration along the cementa! wall of the pocket and
maintaining space for clot stabilization.
• 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
• GTR is often performed with some type of
bone graft as a scaffolding agent, so it is a
combined therapy.

37. Nonresorbable
Membrane
Biodegradable
Membrane

38. • The first commercial membrane was produced from expanded
polytetrafluoroethylene (ePTFE)
• This membrane has all the properties necessary for GTR barriers in
that it
 Is a cellular barrier
 Is biocornpatible
 Provides space for the healing tissue
 Permits tissue integration
 Is clinically manageable.
• After membrane placement, healing is allowed to proceed for 4-6
weeks
• After membrane removal, the area should not be probed for 3 months.
Radiographic evidence of bone fill is usually present after 6 months
and should continue over the course of 1 year.
• In intrabony and fur- cation defects, there are gains in CAL (3-6 mm),
improved bone levels (2.4-4.8 mm), and probing depth reductions (3.5-
6 mm).
• The advent of titanium-reinforced ePTFE allowed for the formation of
larger spaces, thus permitting correction of larger defects.

40. BIODEGRADABLE MEMBRANE
There are basically three types of bioresorbable
membranes:
Polyglycoside synthetic polymers
 Collagen
 Calcium sulfate

41. Several features make these bioresorbable
membranes easier to manage clinically:
 They are more tissue compatible than
nonresorbable membranes
 The timing for resorption can be regulated by the
amount of cross-linkage in the synthetic polymer
and collagen membrane or the amount of heat-
processed calcium sulfate chips in calcium sulfate
barrier
 A second surgical procedure is not required to
retrieve the nonresorbable membrane.

44. • The role of laser in periodontal therapy has
gained popularity
• the use of neodymium-yttrium- aluminum-
gamet (Nd:YAG) to perform surgical LANAP has
been reported for the management of chronic
periodontitis and can potentially result in new
attachment and periodontal regeneration.

46. Biomodification of Root Surface

47. • Changes in the tooth surface wall of periodontal pockets
interfere with new attachment. Although these obstacles
to new attachment can be eliminated by thorough root
planing, the root surface of the pocket can be treated to
improve its chances of accepting the new attachment of
gingival tissues.
• Several substances have been proposed for this
purpose including
 Citric acid
 Fibronectin
 Tetracycline.

48. Advanced Techniques

50. • The natural healing process usually results in tissue
scarring or repair.
• Using tissue engineering, the wound healing process is
manipulated so that tissue regeneration occurs.
• It consists of three key elements:

51. • Tissue engineering principles include the use of
bone allografts and autologous platelet-rich
plasma (PRP).
• Tissue engineering is now clinically applicable
with two commercially available tissue-
engineering systems for periodontal
regeneration which involve the use of EMD and
platelet derived growth factor BB (PDGF-BB)
with beta tricalcium phosphate (TCP).

52. Recombinant Human Platelet Derived
Growth Factor

53. • Platelet-derived growth factor (PDGF) is one of the
earliest growth factors studied for its effect on
wound healing because it is a potent mitogenic and
chemotactic factor for mesenchymal cells in cell
culture
• Histological evidence of periodontal regeneration
was present with excellent furcation fill.
• Recently a biomaterial consisting of 0.3mg/ml of
rhP- DGF + TCP (GEM21S, Osteohealth, Shirley,
NY) was found to significantly improve attachment
level gain, bone level, and bone volume compared to
TCP alone.

54. CONCLUSION
• Periodontal regeneration continues to be one of the
primary therapeutic approaches toward the management
of periodontal defects.
• Although evidence suggests that present regenerative
techniques can lead to periodontal regeneration, the use
of GTR, and biological modifiers can enhance these
results.
• The maintenance of positive results is highly dependent
on patients oral hygiene habits and compliance with
periodontal maintenance.