RECONSTRUCTIVE PERIODONTAL

SURGERYPresented By:

Dr. Manish AshtankarMDS

Periodontics and Implantology

• CONTENT• EVALUATION OF NEW ATTACHMENT AND PERIODONTAL

RECONSTRUCTION• Clinical Methods• Radiographic Method• Surgical Reentry• Histological Method• RECONSTRUCTIVE SURGICAL TECHNIQUE• Non-Bone-Graft-Associated New Attachment• Graft Material and Procedure• Combined Technique• SUMMARY

HEALING

EVALUATION OF NEW ATTACHMENT AND PERIODONTAL RECONSTRUCTION

• New attachment has occurred• Extent?

Clinical Method

Radiographic method and Surgical Reentry

Sources of Cells during healing

What we want to achieve

RECONSTRUCTIVE SURGICAL TECHNIQUE

• NON BONE GRAFT ASSOCIATED• Removal of JE and Pocket Epithelium• Why????• Curettage• CHEMICAL AGENT-sod hypo., sodium sulphide, phenol camphor, antiformin• Ultrasonographic methods• Lasers• SURGICAL TECHNIQUE- Excisional new attachment procedure,

Gingivectomy to the crest of alv. bone and debridement of defect

Curettage

Prevention Of Impending Of Epithelial Migration

• Removal of interdental papilla and replacement by autogenous free gingival graft from palate.

• Coronally displaced flap-increase the distance between epithelium and wound area.

Guided Tissue Regeneration

BASIC PRINCIPLE

RESORBABLE

• Collagen membrane• Vicryl membrane(polyglactin 910)• Polylactic acid membrane• Cargile membrane• Oxidised cellulose membrane• Hydrolyzable polyester• Autogenous PERIOSTEUM

Clot Stabilization, Wound Protection, And Space Creation

• Preservation of root surface –fibrin clot interface• Prevent apical migration of gingival epithelium• Allow for connective tissue attachment• Titanium reinforced ePTFE membrane• Prevent Collapse— Resorbable membrane

Bio-modification of root surface

• Why required???• Citric acid• Fibronectin – glycoprotein-fibroblast require to attach to

tooth surface• Tetracycline-increases binding of fibronectin-turn

stimulate fibroblast attachment-suppress epithelial cell attachment and migration

Citric acid

• pH-1.0-1.4• Application time-2or 3 min.• Mode of action• Removal of smear layer formed after root planing

• This creates a mat like collagen surface with exposed dentinal tubules

• PDL cells and gingival FIBROBLASTS adhere better to demineralized root surface.

•

CITRIC ACID MECHANISM FOR GAINING ROOT COVERAGE

• EXPOSED ROOT SURFACE

• CITRIC ACID Ph 1.0

• 4microns DEMINERALIZED SURFACE EXPOSED COLLAGEN FIBRILS +EXPOSED COLLAGEN FIBRILS OF FLAP OR GRAFT.

• PLASMA FIBRONECTIN FACTOR,FACTOR 13

• FIBRIN COVALENT LINKAGE

Actions

• Accelerated healing and new cementum formation.• No significant action on non-root planed roots,after root

planing-4mm deep demineralized zone is created.• Antibacterial effect.(Daly,1982)• Root detoxification(Aleo et al,1975)• Prevents migration of epithelium .• Enhanced fibroblast growth and stability(Boyko et

al ,1980)• Attachment by direct linkage.

TECHNIQUE OF APPLICATION

Raise a muco

periosteal flap

Thoroughly

instrument root

surface, removing calculus

and cementu

m.

Apply cotton

pledgets soaked in

a saturated solution of citric acid and leave for

2 to 5 min.

Remove pledgets

and irrigate

root surface

profusely with

water

Replace the flap

and suture.

Biologic Mediators

• Involved in regulation of wound healing events• Physiologic molecules, molecules released by cells, or

derivative of such molecules.• Function: autocrine or paracrine metabolism• Act locally or systemically to affect growth and

differentiation of distant cells and tissue• Polypeptide growth factors, differentiation factors, EMP,

attachment factors or proteins involved in bone metabolism

• Secreted by: macrophages, endothelial cells, fibroblasts, and platelets include

• Platelets derived growth factors(PDGF), • Insulin like growth factors(IGF), • basic fibroblast growth factors(bFGF),• Bone morphogenic proteins(BMP), • Transforming growth factors(TGF)

• Action: stimulate –wound healing—promote migration and proliferation of

fibroblast for PDL formation and promote differentiation of cells to become osteoblast –favoring bone formation

Enamel Matrix Protein

• Amlogenin- secreted by HERS – tooth development—Acellular Cementum

formation– favor periodontal regeneration.• Emdogain – marketed product [FDA approved]

Price $. 075.113. 0.3ml

• Viscous gel- contain enamel derived proteins from tooth buds in a polypropylene liquid; 1 ml of vehicle solution mixed with powder

• 90% protein – amelogenin

• Rest- proline-rich nonamelogenins, tuftlin, tuft protein, serum proteins,

ameloblastin, and amelin.

Technique

• Raised flap• Debridement , control bleeding in defect• Root surface treatment –citric acid or 24% EDTA(pH-6.7),

15 sec• Rinse with saline• Apply gel• avoid contamination of wound by saliva and blood• suture • Systemic antibiotic[ doxycycline 100 mg ] for 10 to 21

days recommended

v

Action

• Promote bone cell attachment and cell spreading.• Enhance proliferation of more immature bone cells• Stimulating differentiation of more mature bone cells• Not osteo-inductive but “ osteopromotive”• Stimulate bone formation when combined with DFDB

Graft Materials and Procedures• Bone graft are the materials used for replacement or

augmentation of the bone

• Classification:• Autograft (from same individual)• Allograft/Homograft (different individual -- same species)• Xenograft/Heterograft (different species)• Alloplast (A synthetic graft or inert foreign body implanted

into tissue)

Properties

• Osteogenesis: • Osteoblast in transplanted bone having

adequate blood supply and cellular viability

• Form a new center of ossification within the

graft

Osteoinduction

• Cell mediators at the defect (BMP)

• Stimulation of Osteoprogenitor cells

• Osteoblast

• New bone formation

Osteoconduction

• Physical effect by which the matrix of graft form a scaffold that favors outside cells to penetrate the graft and form a new bone

Autogenous Bone Graft

• Cortical bone chips• Osseous coagulum• Bone blend• Bone swaging• Intraoral cancellous bone marrow transplant

Autogenous Bone Graft

Extraoral Site

Postoperative infection, exfoliation, Sequestration, root resorption, Varying rates of healing,Root resorption,rapid recurrence defectExpences of treatmentTrauma to the patient

Allograft and Xenograft

• Foreign to body---risk to provoke immune response• Suppress antigenic potential—by radiation, freezing, chemical

treatment• Allograft –DFDBA(Decalcified Freeze-Dried Bone Allograft ), FDBA• Commercially obtained—cortical bone—12 hours—death of DONOR---Defatted----cut in pieces---washed in absolute alcohol---deep frozen• May be demineralized then---ground and sieved---250 to 750um and • Freeze-dried• Finally Vacuum sealed in glass vials

• FDBA--- Osteoconductive • DFDBA– Osteoinductive• DFDBA more osteogenic---so preferable• DFDBA—Demineralisation—in cold, diluted HCL acid• Exposes –component of bone matrix---BMPs[bone

morphogenetic protein]• Cancellous DFDBA>>>Cortical DFDBA

• Osteogenin or BMP3 –bone inductive protein isolated from the extracellular matrix of human bone—tested and found to enhance osseous regeneration.

Xenograft• Calf bone [ Boplant –treated by detergent extraction—sterilized—freeze-dried.

• Kiel bone is calf or OX bone –denatured with 20% H2O2---Dries with Acetone— Sterilized with ethylene oxide.

• Anorganic bone is OX bone—organic material extracted by---ethylenediamine--- then sterilized by autoclaving.

• Ospurane : cow bone soaked in KOH , acetone and salt solution

• Boiled Bone: cow bone boiled or autoclaved

• Bio-Oss: anorganic, osteoconductive, porous bone mineral matrix from

bovine cancellous or cortical bone.

• Physical feature—trabecular architecture and porosity– permit clot

stabilization and revascularization—allow for migration of osteoblasts, leading to osteogenesis.

Non Bone Graft Materials

• Sclera, dura, cartilage, cementum, dentin, plaster of paris, plastic materials,

ceramics and coral derived materials.• Not a reliable substitute.

Sclera

• dense, fibrous connective tissue with poor vascularity & minimal cellularity• Low incident of antigenicity• Provide barrier to apical migration of junctional epithelium• Protect blood clot during initial healing period• Well accepted by host , invaded by host cells and capillaries• No induction of osteogenesis or cementogenesis

• Cartilage: serves as a scaffolding, received limited evaluation

• Plaster of Paris [calcium sulfate] : biocompatible, porous, allowing fluid exchange, resorbs completely in 1 to 2 weeks.

• Usefulness in human studies not proved• Plastic material : composite of Polymethyl-methacrylate

and Polyhydroxyethylmethacrylate.

Calcium Phosphate Biomaterial

• Osteoconductive, excellent tissue biocompatibility, no inflammation or foreign body response.

• Two Types: Hydroxyapatite(HA): calcium : phosphate ratio : 1.67

• Tricalcium phosphate (TCP) : 1.5

Bioactive Glass

• Consist of : sodium and calcium salts, phosphates, and silicon dioxide

• Used in the form of irregular particles measuring 90-170um or 300-355um

• When this material comes in contact with tissue fluids, the surface of

particles become coated with hydroxycarbonate apatite, incorporates organic proteins such as chondroitin sulfate and glycosaminoglycans and attract osteoblast.

Coral Derived Material

• Two types: • Natural coral [resorbed slowly-several months]• Coral derived porous hydroxyapatite [ years for

resorption]• Shows microscopic cementum and bone formation• But slow resorbability —limited clinical success

Combined technique

• Froum et al : criteria for choice of treatment• Clinical result depend upon:• 1) dimension and morphology of defect( deeper>shallower)• 2) number of walls• 3) amount of root surface exposed and ability to obtain

adequate flap coverage• 4) angle of defect with long axis of tooth (smaller – better)

Clinical Decision Tree

• For Deep, Well-Contained Defects—EMD alone, CAF (if necessary)• For Moderate-Deep, Noncontained defects- EMD+Graft, CAF(if

necessary)• For Supracrestal Defects with a shallow Vertical Defect- EMD+Graft+Barrier membrane, with Coronally Advanced Flap

EMD- enamel matrix derivative. Emdogain[Froum et al 2001]

References

• Carranza 10th ed. and 12th ed.