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Chapter #61

Hisham AlShorman
Aya AlHelo & Esraa Jaradat


Antiformin. Excellent results have been obtained with this technique in uncontrolled human studies. Ultrasonic methods. Successful repair of osseous lesions in the submerged environment was reported. The drugs used sodium sulfide. II. C-Surgical Techniques. Recommended to eliminate the pocket and junctional epithelium. -New attachment is more likely to occur when the destructive process has occurred rapidly such as after treatment of pockets complicated by acute periodontal abscesses and after treatment of acute necrotizing ulcerative lesions. *These include careful case selection and complete removal of all irritants on the root surface. but this method has little or no clinical application. . in the great majority of cases it should be done after exposure of the area with a flap. No attempt is made to elevate a flap.the epithelium from the excised margin may rapidly proliferate to become interposed between the healing connective tissue and the cementum.Curettage. coronally displaced flaps: increase the distance between the epithelial wound edge and the healing area.Removal of Junctional and Pocket Epithelium. The graft simply delays the epithelium from proliferating into the healing area. The excisional new attachment procedure consists of an internal bevel incision performed with a surgical knife. 2. Several methods have been recommended to remove the junctional and pocket epithelium these include : A. III. interproximal sutures are used to close the wound * Glickman and Prichard have advocated performing a gingivectomy to the crest of the alveolar bone and debriding the defect. This is particularly suitable for the treatment of mandibular molar furcations and has been used mostly in conjunction with citric acid treatment of the roots. This not only excludes the epithelium but also prevents microbial contamination of the wound during the reparative stages. lasers. *Trauma from occlusion. but their effects cannot be controlled because of the clinician’s lack of vision and tactile sense when using these methods B-Chemical Agents. The effect of these agents is not limited to the epithelium. Total removal of the interdental papilla covering the defect and its replacement with a free autogenous graft obtained from the palate During healing. and sodium hypochlorite. may impair post treatment healing of the supporting periodontal tissues. Therefore it is not a reliable procedure. limiting the height to which periodontal fibers can insert to the cementum. After careful scaling and root planing. I. followed by removal of the excised tissue. vary from complete removal to persistence of as much as 50%. phenol camphor. Elimination of the junctional and pocket epithelium may not be sufficient . Occlusal adjustment is therefore indicated. *Systemic antibiotics are generally used after reconstructive periodontal therapy.Reconstructive techniques * Subdivided into two major types: 1) non–bone graft–associated new attachment 2) bone graft–associated new attachment. Usually in conjunction with curettage. Rationale and techniques that must be considered for a successful outcome in periodontal bone regeneration: 1. Results of removal of the epithelium . *can be done in some cases as a closed procedure. and their depth of penetration cannot be controlled. * The modified Widman flap is similar to the excisional new attachment procedure but is followed by elevation of a flap for better exposure of the area. Presence of junctional and pocket epithelium has been perceived as a barrier to successful therapy because its interferes with the direct apposition of connective tissue and cementum. Not widely used. Non–Bone Graft–Associated Procedures . The internal bevel incision eliminates the pocket epithelium. the graft epithelium necroses and is slowly replaced by proliferating epithelium from the gingival surface. “Root submergence” : excluding the epithelium by amputating the crown of the tooth and covering the root with the flap.Attained without the use of bone grafts in meticulously treated three-wall defects (intrabony defects) and in periodontal and endodontic abscesses. and rotary abrasive stones have also been used.Prevention or Impeding the Epithelial Migration.

This was accomplished after the initial stages of healing. but bone level measurements have been inconclusive. 6. the tissues are anesthetized. Raise a mucoperiosteal flap with vertical incisions. * The use of polytetrafluoroethylene (PTFE) membranes has been tested in controlled clinical studies in mandibular molar furcations and has shown statistically significant decreases in pocket depths and improvement in attachment levels after 6 months.Guided tissue regeneration: The method for the prevention of epithelial migration along the cemental wall of the pocket and maintaining space for clot stabilization (GTR) GTR consists of placing barriers of different types (membranes) to cover the bone and periodontal ligament. the patient is placed on antibiotic therapy for 1 week. Histologic studies in humans provided evidence of periodontal reconstruction in most cases. the margin of the membrane may become exposed. Wound Protection. Excluding the epithelium and the gingival connective tissue from the root surface during the postsurgical healing phase not only prevents epithelial migration into the wound but also favors repopulation of the area by cells from the periodontal ligament and the bone. The apical border of the material should extend 3 to 4 mm apical to the margin of the defect and laterally 2 to 3 mm beyond the defect. 3. therefore the resorbable membranes were developed.Clot Stabilization. and Space Creation. minimizing trauma to the underlying tissue. Transference of this concept to periodontal therapy has been explored for treatment of periodontal and periimplant osseous defects and for root coverage. The flap should cover the membrane completely. * Initial animal experiments using Millipore filters and Teflon membranes resulted in regeneration of cementum and alveolar bone and a functional periodontal ligament.The results obtained with the GTR technique are enhanced when the technique is combined with grafts placed in the defects . 3 to 6 weeks after the first intervention. temporarily separating them from the gingival epithelium and connective tissue. The second procedure was a significant obstacle in the utilization of the GTR technique. The space can be created by using a titanium-reinforced expanded polytetrafluoroethylene (ePTFE) membrane to prevent its collapse. using independent sutures interdentally and in the vertical incisions. 3. A study on maxillary molar furcations did not result in significant gain in attachment or bone levels. 4. The occlusal border of the membrane should be placed 2 mm apical to the cementoenamel junction.Periodontal dressings is optional. Debride the osseous defect and thoroughly plane the roots. Suture the membrane tightly around the tooth with a sling suture.  The ePTFE membrane (nonresorbable) can be obtained in different shapes and sizes to suit proximal spaces and facial/lingual surfaces of furcations . Trim the membrane to the approximate size of the area being treated. * The initial membranes developed were nonresorbable and required a second surgical procedure to remove them. Suture the flap back in its original position or slightly coronal to it. The technique for its use is as follows 1. even with horizontal bone loss.If it cannot be removed easily. 4. extending a minimum of two teeth anteriorly and one tooth distally to the tooth being treated. and the material is surgically removed using a small flap. *After 4 to 6 weeks. The membrane is removed carefully. 2. 5.

Bone graft materials are also evaluated based on : 1. fibronectin. It is difficult to find a material with all these characteristics. C) xenografts are bone from a different species. a polylactic acid gel. degenerated remnants of Sharpey’s fibers.clinical feasibility. and trimethylene carbonate that resorbs at 6 to 14months.Llactide-co-glycolide (Resolut membrane. and epithelial cells may proliferate into the defect. occlusal adjustment as needed. bone morphogenetic proteins) convert the neighboring cells into osteoblasts. one of grade II furcation involvements in mandibular molars and another of interdental defects. no longer on the market) and a poly-D.Osteogenesis refers to the formation or development of new bone by cells contained in the graft. polylactic acid. minimal operative hazards. All grafting techniques require presurgical scaling.polylactic acid. porcine.Osteoinduction is a chemical process by which molecules contained in the graft (e.g.g. predictability. *Resorbable membranes has included trials and tests with numerous materials and collagens from different species such as bovine. resulting in contamination and possible exfoliation of the grafts. and freeze-dried dura mater *Co-polymers derived from polylactic acid and acetyl tributylcitrate resorbable membranes (Guidor membrane. a bovine Achilles tendon collagen that resorbs in 4 to18 weeks. also no longer on the market) have shown significant gains in clinical attachment and bone fill. considerations that govern the selection of a material as follows: biologic acceptability. . *Several substances have been proposed for this purpose. *Changes in the tooth surface wall of periodontal pockets (e. minimal postoperative sequelae. Biodegradable Membranes. -Atrisorb (Block Drug). -BioMend(Calcitech).BioGuide (Osteohealth). Periodontal defects as sites for transplantation differ from osseous cavities surrounded by bony walls. The flap technique best suited for grafting purposes is the papilla preservation flap because it provides complete coverage of the interdental area after suturing . which in turn form bone.Biomodification of Root Surface. 3. Graft Materials and Procedures The following classifications of bone graft material are important to note: A) autografts are bone obtained from the same individual B) allografts are bone obtained from a different individual of the same species.. disintegration of cementum and dentin) interfere with new attachment. * Resorbable membranes marketed in the United States (US) include: -OsseoQuest (Gore). 2. accumulation of bacteria and their products. a combination of polyglycolic acid. 5. and patient acceptance. *The use of membranes is usually combined with autogenous bone from adjacent areas or other graft materials and root biomodifiers *The potential of using autogenous periosteum as a membrane and also to stimulate periodontal regeneration has been explored in two controlled clinical studies. and exposure of the defect with a full thickness flap. synthetic skin (Biobrane). *The periosteum was obtained from the patient’s palate by means of a window flap. Therefore the principles established to govern transplantation of bone or other materials into closed osseous cavities are not fully applicable to transplantation of bone into periodontal defects. BioGuide is the most popular resorbable membrane. these. a bilayer porcine-derived collagen. * Both studies reported that autogenous periosteal grafts can be used in GTR and result in significant gains in clinical attachment and osseous defect fill. Vicryl (polyglactin 910). The use of antibiotics after the procedure is generally recommended . *These obstacles to new attachment can be eliminated by thorough root planning. including citric acid. Cargile membrane. and tetracycline..Osteoconduction is a physical effect by which the matrix of the graft forms a scaffold That favors outside cells to penetrate the graft and form new bone. Saliva and bacteria may easily penetrate along the root surface.

bone from edentulous ridges. Bone Blend technique : To overcome disadvantages of osseous coagulum . bone is removed with a curved rongeur. Extraction sockets are allowed to heal for 8 to 12 weeks before reentering and removing the newly formed bone from the apical portion. newly formed bone in wounds. or trephine. and the ramus and bone removed during osteoplasty and Ostectomy Osseous Coagulum. can be obtained from the maxillary tuberosity. The disadvantages are its relatively low predictability and the inability to procure adequate material for large defects. triturated in the capsule to a workable. Technique described by Robinson using a mixture of bone dust and blood using small particles ground from cortical bone. edentulous ridges. exostoses. Sources of the graft material : lingual ridge on the mandible. The method was revived by Nabers and O’Leary in 1965. And inability to use aspiration during accumulation of the coagulum. the location of the maxillary sinus must be analyzed on the radiograph to avoid entering or disturbing it. bone removed from tuberosity. and healing sockets.Autogenous Bone Grafts:  Bone from Intraoral Sites. and packed into bony defects. Froum et al found osseous coagulum–bone blend procedures to o be at least as effective as iliac autografts and open curettage. and the lingual surface of the mandible or maxilla at least 5 mm from the roots. and numerous efforts have been made since that time to define its indications andtechnique. The obvious advantage of this technique is the ease of obtaining bone from a area already exposed during surgery. Bone is removed with a carbide bur #6 or #8 at speeds between 5000 and 30. the “bone blend technique” has been proposed. the particle size provides additional surface area for the interaction of cellular and vascular elements. particularly if the third molars are not present. Cancellous Bone Marrow Transplants. placed in a sterile dappen dish and used to fill the defect. Care should be taken not to extend the incision too far distally to avoid entering the mucosal tissue of the pharyngeal area. ** Sources of bone include bone from healing extraction wounds. edentulous areas. plasticlike mass. Another problem is the unknown quantity and quality of the bone fragments in the collected material. Edentulous ridges can be approached with a flap. which is used as the donor material. . bone removed by osteoplasty or ostectomy. bone trephined from within the jaw without damaging the roots. back-action chisels. the bone distal to a terminal tooth. and cancellous bone and marrow are removed with curettes. Bone is removed from a predetermined site. The maxillary tuberosity frequently contains abundant cancellous bone. The bone blend technique uses an autoclaved plastic capsule and pestle. After a ridge incision is made distally from the last molar.000 rpm.

if still present. Bone swaging is technically difficult. It has also been successful in furcations and even supracrestally to some extent. using bone from the tibia.The material is then treated with chemical agents or strong acids to inactivate the virus. Allografts. the technique is no longer in use.Undecalcified Freeze-Dried Bone Allograft. Bone allografts are commercially available from tissue banks. varying rates of healing. The material may then be demineralized. Attempts have been made to suppress the antigenic potential of allografts and xenografts by radiation. from which the bone is pushed into contact with the root surface without fracturing the bone at its base. cut in pieces. steps taken to eliminate viral infectivity: 1. root resorption.Bone Swaging. washed in absolute alcohol.  Bone from Extraoral Sites. Hegedüs also pioneered the use of extraoral sites as a source of bone for grafting into periodontal osseous defects. and subsequently ground and sieved to a particle size of 250 to 750 μm and freeze-dried. Other problems were increased patient expense and difficulty in procuring the donor material. sequestration. . (the risk of HIV infection in 1 in 1-8 million  highly remote) 2. and its usefulness is limited. Finally. and chemical treatment. bone exfoliation. types of allografts: 1. freezing. it is vacuum-sealed in glass vials.exclusion of donors from known high-risk groups and various tests on the cadaver tissues to exclude individuals with any type of infection or malignant disease. They are obtained from cortical bone within 12 hours of the death of the donor. and deep-frozen. and rapid recurrence of the defect (Figure 61-15). Schallhorn and Hiatt revived this approach in the 1960s using the iliac crest Iliac Autografts. both allografts and xenografts are foreign to the patient and therefore have the potential to provoke an immune response. This material has been used by orthopedic surgeons for years. defatted. In 1923. This technique requires an edentulous area adjacent to the defect. Data from human and animal studies support its use. and the technique has proved successful in osseous defects with various numbers of walls. Some of the problems were postoperative infection.

Xenografts. These include sclera. ceramics. plastic materials. cementum. sterilized. porous bone mineral matrix from bovine cancellous or cortical bone. and freeze-dried. The recognition that new tissues are formed by cell populations have resulted in efforts to stimulate the cells that are located in the periodontal defect  One way to stimulate these cells is to use proteins (growth factors) that can bind to surface receptors on the cell membranes. treated by detergent extraction. . showed new attachment and periodontal regeneration in defects grafted with DFDBA  so results in significant probing depth reduction. dura. areas of Teeth undergo careful root Area is sutured. Laboratory studies have found that DFDBA has a higher osteogenic potential than FDBA and is therefore preferred. periodontal bone loss are planing. eliciting no systemic immune response. has been used for the treatment of osseous defects. . but the trabecular architecture and porosity are retained. dentin. it is then sterilized by autoclaving  The organic components of the bone are removed. Nonbone Graft Materials. FDBA (freeze-dried bone allograft) is considered an osteoconductive material. cartilage. termed osteogenin or BMP-3. It is an osteoconductive. DFDBA tested against autogenous materials and showed it to have similar osteogenic potential. which in turn trigger a series of events to occur that alter the genetic activity of the cell with the result that cell behavior is stimulated. None offers a reliable substitute to bone graft materials. ** A bone-inductive protein isolated from the extracellular matrix of human bones. Currently. has been tested in human periodontal defects and seems to enhance osseous regeneration. and osseous regeneration. which are closely associated with collagen fibrils and have been termed bone morphogenetic proteins (BMPs)**. After raising a flap. So new therapeutic approaches for periodontal regeneration have been sought. osteogenic potential. and Bio-Oss graft is clearly placed in the defects. an anorganic**. Bio-Oss is biocompatible with the adjacent tissues. diluted hydrochloric acid exposes the components of bone matrix. Demineralization in cold. Calf bone (Boplant). but this is usually limited to the base or apical aspect of the defect and the resultant tissue formation is not sufficient in terms of quantity or predictability. leading to osteogenesis. bovine-derived bone marketed under the brand name Bio-Oss (Osteohealth) has been successfully used both for periodontal defects and in implant surgery. .Demineralized Freeze-Dried Bone Allograft. and coral-derived materials. whereas demineralized FDBA (DFDBA) is considered an osteoinductive graft. . . attachment level gain. plaster of Paris. . Biologic Mediators: Bone grafting attempts results in some regeneration. ** Anorganic bone is ox bone from which the organic material has been extracted by means of ethylenediamine. histologic study in humans. The membrane prevents the migration of fibroblasts and connective tissues into the pores and between the granules of the graft. . Cortical DFDBA resulted in more desirable clinical results than cancellous DFDBA. Bone products from other species have a long history of use in periodontal therapy. . The physical features permit clot stabilization and revascularization to allow for migration of osteoblasts. It has been used as a graft material covered with a resorbable membrane (BioGuide). 2.

the formation of bone can be enhanced when growth factors are used to stimulate osteoblast precursor or osteoblast cells and hence to push the bone formation/bone resorption balance in favor of bone formation.3 mg/ml).25 to 1.Raise a flap for reconstructive purposes 2. 3. As BMPs BMP-2 has been shown to have some of the strongest bone producing activity.Complete closure of the wound is necessary. these proteins are believed to favor periodontal regeneration. tuft protein. The extended release kinetics likely allow the undifferentiated mesenchymal cells migrating into the wound site to be exposed to the growth factor. 5. the BMPs induce the differentiation of mesenchymal stem cells to become bone producing osteoblast cells. Enamel Matrix Proteins Purified enamel matrix proteins have been extracted from porcine developing enamel. BMPs are differentiation factors. 6.  These biologic mediators have been used to stimulate periodontal wound healing (e. basic fibroblast growth factor (bfGF). The technique using enamel protein derivatives. allograft.5 cc of beta-tricalcium phosphate (β-TCP) particles. are secreted by Hertwig’s epithelial root sheath during tooth development and are known to induce acellular cementum formation. GEM 21S consists of 0. . tuftelin. promoting migration and proliferation of fibroblasts for periodontal ligament formation) or to promote the differentiation of cells to become osteoblasts. mainly amelogenin. Ninety percent of the protein in this mixture is amelogenin. BMP. and gingival recession associated with periodontal defects. as described by Mellonig: 1. and apply the gel to completely cover the exposed root surface. the enamel matrix derivative is not osteoinductive.. and transforming growth factor (TGF). which acts as the carrier. (0.Demineralize the root surface with citric acid. thereby favoring bone formation.Remove all granulation tissue and tissue tags.Completely control bleeding. . The enamel matrix proteins. insulinlike growth factor (IGF). 4. .g. A periodontal dressing is preferred to protect the wound.5 ml rhPDGF-BB (0. furcation periodontal defects. As a growth factor. The bone morphogenetic proteins are a group of related proteins that are found in the body and are important for skeletal development.Rinse the wound with saline. Cell behavior: either cellular proliferation or cellular differentiation. but it is “osteopromotive” in that it stimulates bone formation when combined with demineralized FDBA. and 0. As mentioned earlier. or alloplast. and their use for periodontal tissue regeneration has shown mixed results in the numerous studies that have been conducted. The commercially available bone growth product contains rhBMP-2 combined with a bovine type I collagen sponge. including autograft. The root surface should be thoroughly planed. But no regenerative indicatios in alveolar bone defects and sinus augmentation.0 mm). the type of attachment achieved during periodontal reconstructive therapy can only be determined histologically. GEM 21S: (recombinant human rhPDGF-BB). This commercial product is indicated in the treatment of intrabony periodontal defects. Besides the bone replacement graft materials. These growth factors include platelet-derived growth factor (PDGF). with the rest primarily proline-rich non-amelogenins. xenograft. A systemic antibiotic coverage for 10 to 21 days is recommended. Example: trade name Emdogain. serum proteins. and amelin. ameloblastin.

the better chance of success).the amount of root surface exposed and the ability to obtain adequate flap coverage. 2. and coverage with a nonresorbable membrane.The number of walls in the defect75 (three-wall defects have greater potential to fill than two-wall or one-wall defects). . combination technique using graft material. has resulted in an increased percentage of cases with successful new attachment and periodontal reconstruction the criteria that should guide the choice of treatment technique (by Froum): 1. other combination techniques have been advocated. matrix protein (Emdogain). Example: in 1088.the dimension and morphology of the defect (deeper lesions result in greater bone fill than shallower defects). with the advent of osteopromotive agents. along with autogenous bone with resorbable membrane coverage. and defect filled with enamel later. root conditioning with citric acid. clinicians have combined these graft materials along with the use of membranes in a attempt to find a predictable technique to regenerate bone. extensive bone fill. 4. Combined Techniques To take advantage of the different bone graft materials and biologic mediators. root prepared.Deep vertical bone loss distal Area flapped. More recently. Postoperative photo 6 months Reentry surgery showing to lower left central incisor. such as the enamel matrix derivative (Emdogain) and osteoconductive bovine-derived anorganic bone (Bio-Oss) graft materials. The combined use of these products.the angle of the defect to the long axis of the tooth193 (the smaller the angle. 3.