Dr S Olusegun Nwhator (BDS, FMCDS, FWACS)

Senior Lecturer/Consultant Periodontologist

Lead Researcher, Periodontal Medicine Research Group

Treatment of Osseous Defects

1. Osseous Resection
2. Debridement
3. Grafting

Infrabony Defect
Base of pocket is apical to the alveolar crest
One osseous wall
Two osseous walls
Three osseous walls

Ostectomy vs osteoplasty
Ostectomy resecting --sacrifice some supportive bone
Osteoplasty-- Reshaping without sacrificing supporting bone

Indications for Osseous Resection

Wide 3-wall defects
Interproximal craters
Hemiseptums
Furcations
Thick alveolar bone

Indications for bone grafts

Periodontal defects
Alveolar ridge augmentation
Extraction site bone fill
Sinus augmentation

Types of bone grafts

Autografts
Maxillary tuberosity
Mandibular ramus
Chin
Extraction socket
Tori
Edentulous ridges

Osseous Coagulum
Exotoses, edentulous ridge
Bone Dust & Blood
Crbide bur (5,000-30,000 rpms)
Pack coagulum into defect
Small particles more active in inducing
regeneration of periodontium

Allografts
Bone from another human (Cadaver)
lIiac cancellous bone
Freeze-dried (50% fill)
Decalcified freeze-dried
(Cortical better than cancellous)

Bone Morphogenic Proteins (1-9)

Protein with osteogenic potential
Advantages of Allograft Bone
No donor site morbidity
Preservation of patients tissue
Reduced surgical time
Availability
Utility

Demineralized Freeze Dried Bone

From cadavers
Advantages
Quantity
Predictability
No adverse reactions

Non Bone Graft Materials

Glass granules
Plastic Materials (HTR Polymers)
Tricalcium phosphate
Plaster of Paris (CaSO4)
Hydroxyapatite
Cartilage
Sclera
Calcium Phosphate
Others

Can allografts transfer disease?

Considered safe

Guided Tissue Regeneration

FACULTY OF DENTAL SURGERY
WEST AFRICAN COLLEGE OF SURGEONS
UPDATE COURSE IN CLINICAL DENTISTRY
05/02/2015

The Junctional Epithelium

Forms the base of the sulcus
Joins gingiva to tooth surface
Ranges from 0.71 to 1.35 mm
15 to 30 cells thick at coronal zone
4 to 5 cells thick at apical zone
Non-keratinized
Wide intercellular spaces and desmosomes
Dense granules
Permeability barrier,
Phagocytotic activity
Derived from the reduced enamel epithelium

The Disease Process

The Disease Features

Bleeding on probing
Epithelial migration of the JE
Pocket formation
Suppuration
Pocket ulceration
Pockt deepens and anerobic environ
perpetuates inflammation

Intervention-Periodontal therapy

Intervention-Periodontal therapy

Ultimate Goal
To achieve healing and the restoration of
periodontal health.

Scaling and root planing goals

To remove calculus
To provide a smooth surface
To remove endotoxin
Reduced bleeding
Gingival shrinkage (by 2 wks),
Connective tissue reattachment (by 4wks)
Probing pocket depth reduction
Reduced tooth mobility

Do we achieve this goal???

Defining terms
Repair - Epithelial adaptation
New Attachment formation
Regeneration

Repair
Restablishes a normal gingival sulcus
Arrest bone destruction
No gain in clinical attachment
No gain in bone height

Is this the ultimate goal???

Reattachment
Repair of areas not previously exposed to the pocket
After cemental fractures or treatment of
periapical lesions
Attachment of flap to areas of the tooth from which
it has been removed in the course of
treatment

Is this the ultimate goal???

Epithelial Adaptation
Close apposition without gain in height of
gingival attachment-Long junctional
epithelium to the tooth surface,
Epithelium Attachment

Is this the ultimate goal???

New attachment
Attachment of new PDL fibers into
new cementum on a tooth surface with
adequate bone support in areas previously
lost to disease.

Is this the ultimate goal???

If yes, how do we achieve it?

Achieving the goal

New periodontal ligament fibers

New cementum
Adequate bone support
In areas previously lost to disease.
New attachment

Obstacles!!
Fast-moving epithelial tissue in JE
JE migrates into the defect space
Cementum excluded
Periodontal ligament excluded

Result=long junctional epithelium

Why the obstacles!

Different origins of periodontal tissues
Difference growth rates of periodontal tissues
Epithelial growth ahead of mesenchymal
At best, epithelial growth only achieves
Epithelium Attachment
Long junctional epithelium
Close apposition without gingival attachment

Is this the ultimate goal???

Is this the ultimate goal???

Addressing the obstacles

Difference growth rates of periodontal tissues
Rational for intervention:
== create an environment to allow for
differences in growth rate.

Addressing the obstacles

Epithelial growth ahead of mesenchymal
Rational for intervention
== Exclude the epithelium to differentially allow
for growth and attachment of the mesenchymal
tissues to the treated root surface.

Addressing the obstacles

Epithelium Attachment
Rational for intervention:
== aim to obtain a new attachment of actual
periodontal tissues like the PDL, cementum and
alveolar bone.

Addressing the obstacles

Long junctional epithelium
== Prevent the formation of long junctional
epithelium by keeping the junctional epithelium
away long enough to allow for new attachment
of PDL and cementum to the root surface.

Addressing the obstacles

Close apposition without gingival attachment
Rational for intervention:
== Achieve close adaption with new periodontal
tissues to achieve new attachment.

Ultimately

Create an environment to allow for differences in growth rate.

Exclude the epithelium to differentially allow for growth and
attachment of the mesenchymal tissues to the treated root
surface.
Obtain a new attachment of actual periodontal tissues like the
PDL, cementum and alveolar bone.
Prevent the formation of long junctional epithelium by
keeping the junctional epithelium away long enough to allow
for new attachment of PDL and cementum to the root
surface.
Achieve close adaption with new periodontal tissues to
achieve new attachment.

Rational for intervention

Create an environment allowing for different growth rates

Exclude the fast-growing epithelium
Prevent the formation of long junctional epithelium
Achieve close adaption with new periodontal tissues
Obtain a new attachment of actual periodontal tissues

Rational for intervention

Guiding the way the periodontal tissues
regenerate in a way that produces predicable
results.

Guided Tissue Regeneration

History of Guided Tissue Regeneration

Early 1980s
Stre Nyman and Thorkild Karring---influence of 4 tissue
types on periodontal healing
Gingival connective tissue,
Gingival epithelium
Periodontal ligament
Bone
Jan Lindhes leadership

Pioneer Human Experiment

Selectively isolating the gingiva from a healing

periodontal defect could result in regeneration
of the periodontal ligament and cementum.

Barriers timeline

Simple nonporous cellulose acetate filters

Gold foil
Gore- tex--extremely inert and biocompatible
Expanded polytetrafluoroethylene (ePTFE)
Silicone button with pokerchip ePTFE

 pokerchip epTFE---unique node and fibril

structure for rapid cell integration.
over 90% air and internodal spaces of more
than 100 m

Basic principles

Isolation encourages healing of the desired tissue.

A cell isolating biomaterial must meet minimum standards
Structural and biocompatibility requirements are important
Should encourage organized and vascularized ingrowth
Should limit epithelial invagination,
Should promote regenerative rather than scar-type healing
Success depends on flap design and membrane coverage
Membranes should protect the healing tissues

Initial blood clot is important

Grafting materials help maintain volume in regeneration sites
Thorough site preparation/ cleaning, flap preparation
Good primary closure should be aimed at
Adequate vascularity for secondary healing is important
Management of potential infection affects success

Ideal properties of GTR barriers

1. Tissue Integration --allow for organized vascular and
connective tissue ingrowth
2. Encourage regenerative healing and inhibit epithelium
3. Selective cell Separating
4. Provide necessary nutrient, blood supply
5. Clinically Manageable
6. Space-maintaining - for stable clot formation
7. Biocompatible
From 1982-1992: A Decade of Technology Development
of Guided Tissue Regeneration Scantlebury 1993

ePTFE membranes

Initial attempts

Definition
GTR is a procedure through which the
exclusion of epithelial and gingival connective
tissue cells from the healing area by the use of
a physical barrier may allow or guide
periodontal ligament cells to repopulate the
detached root surface. --Chander Kumar

Definition
GTR is a form of periodontal therapy that affords
unimpeded development and movement of
progenitor cells toward the root surface which had
previously undergone attachment loss due to
periodontal disease.
GTR is the facilitated movement of the progenitor
cells toward the treated root surface with exclusion
of gingival epithelial cells and fibroblasts.

Basis
Wound closure is mostly achieved by the
apical migration of gingival epithelial cells.
These cells subsequently adhere to the root
surface resulting in wound closure through a
long junctional epithelial attachment .
The LGE does not resemble the original
attachment apparatus of periodontal ligament
fibers.

Basis
1. The periodontium contains progenitor cells for cementum, pdl and
alveolar bone. Melcher ,1976
2. The progenitor cells reside in the periodontal ligament
3. Gingival connective tissue and gingival epithelium excluded
4. Prevented from contacting the root surface during healing
5. Exclusion achieved with a barrier membrane
6. Regeneration --re constitution /complete restoration
7. Complete restoration of lost or injured perio tissues
8. Reformation of cementum, periodontal ligament & alveolar bone

The GTR Theory

With traditional therapy, restoration of periodontal
tissues previously lost to chronic periodontitis is often
minimal and unpredictable.
Placing a barrier between the overlying gingival tissues
and the bony defect excludes fast-moving epithelium and
gingival cells from contacting the root surface
This gives time for Cementum, periodontal ligament and
bone to repopulate the defect.

The GTR Theory

Progenitor PDL cells differentiate into cementocytes
and periodontal ligament fibroblasts.
These two cells produce a new attachment apparatus
which results in a wound closure which resembles
the attachment apparatus prior to chronic
periodontitis.

Indications for Guided Tissue Regeneration

Two or three wall vertical defects

Interproximal defects
Distal defects
Class II and class III furcation Defects
Gingival recession

Contraindication of Guided Tissue Regeneration

Inadequate zone of gingival tissue
A defect morphology that does not allow for space
creation and maintenance
Uncontrolled diabetes
Anti coagulant therapy
Acute infection/inflammation
Allergy to bovine products

Products for Guided Tissue Regeneration

First Generation:
Millipore filter
Expanded PTFE(Gore-tex)
Nucleopore membrane

Products for Guided Tissue Regeneration

Second Generation (resorbable):
Collagen membrane
Polylactic acid membrane (guidor)
Vicryl mesh
Cargile membrane
Oxidase cellulose
Hydrolysable polyester

Products for Guided Tissue Regeneration

Third Generation:
Resorbable materials + growth factors

Procedure for Guided Tissue Generation

1.
2.
3.
4.
5.
6.
7.
8.
9.

Make an incision using a size 15 surgical blade

Preserve the attached keratinized interdental papillae
Vertical relieving incisions may help create wider access
Vertical incisions 1tooth mesial and/or distal to the site
Raise full thickness flap and perform adequate debridment
Rotary, sonic and ultrasonic devices for SRP are desirable
Measure the defect with a periodontal probe
Select an appropriately sized template and try on defect
Hydrate approximately 5 to 10 minutes

10. Membrane should extend 3mm beyond all defect margins

11. Trim template and place against the collagen membrane
12. Check that membrane is coronal to alveolar crest
13. Check that membrane is apical to the gingival margin
14. Secure membrane in place with a resorbable suture
15. Check that membrane fits snugly against the root
16. Check that membrane is draped over the alveolar bone

How about osseous grafts

Osseous grafts in conjunction with GTR
enhances bone regeneration.
A bone graft could be obtained from the same
patient --autogenous graft or from freezedried human bone graft material --allograft

8 mm pocket

Incision

Root defect exposed

Bio-oss in place

Membrane in place

Sutures in place

Dressing in place

Armamentarium

Post-operative instructions

Chlorexidine mouthrinse- b.d 4-6 wks

Avoid brushing site for two weeks
Gentle brushing - 3 weeks
Resume gentle brushing with a soft toothbrush
Review in 24 hrs, then weekly for 4 weeks
Increase review time as appropriate
Antibiotic coverage - 14 days

Things to note
Membrane should be completely absorbed eight weeks
Evaluate plaque, bleeding and tooth mobility indices
Allow 6 months before probing

Smooth and rough sides

Smooth side is compact and cell occlusive Guarantees
protection against connective tissue.
This side faces the soft tissue.

The rough side consists of collagen fibers

It is loose & porous
It enables cell invasion
It enhances the integration of bone forming cells
It stabilizes the blood clot
This side faces the bone defect

Neonem either side

Smooth & rough sides

Things to look out for!!

Swelling of surgical site
Thermal sensitivity
Excessive gingival bleeding
Dehiscence of flap
Gingival recession.
Root resorption or ankylosis

Different materials
Capset --Calcium sulfate
Resolut-Polyglycolic acid + poly (lactic acid-co-glycolic acid)
Emdogain-Enamel matrix protein+ Amelogenins Porcine
with Surface-cementum forming cells
Biomend--collagen
Guidor--Polylactic acid + citric acid ester
Atrisorb D Free Flow-- 4 % Doxycycline

Success determinants

 Nyman S, Lindhe J, Karring T, Rylander h. New attachment following

surgical treatment of human periodontal disease. J Clin periodontol
1982;9:290-6.
Melcher Ah, Dreyer CJ. protection of the blood clot in healing
circumscribed bone defects. J Bone Joint Surg Br 1962;44-B:424-30.
Dahlin C, Linde A, Gottlow J, Nyman S. healing of bone defects by
guided tissue regeneration. plast Reconstr Surg 1988;81(5):672-6.