REGENERATIVE PERIODONTAL THERAPY-NON BONE GRAFT ASSOCIATED NEW ATTACHMENT

Presented by G. Srinivas Date:09/01/13

Contents
Introduction Definition History Wound healing principle Indications for regenerative therapy Regenerative techniques
1. Non-graft-associated new attachment 2. Graft-associated new attachment

Non-graft-associated new attachment

Removal of junctional and Pocket Epithelium curettage chemical agents ultrasonic methods surgical techniques

Contents
Surgical techniques
Excisional new attachment procedure Prevention of Epithelial Migration Root Biomodification Coronally advanced flap Guided tissue regeneration Guided bone regeneration

Guided tissue regeneration

Biological foundation Classification Objectives of an ideal membrane Indications & contraindications Decision tree for candidates indicated for GTR Complications Infectious aspects of regeneration Anti-infective therapy in periodontal regeneration

Guided bone regeneration

Principles of GBR Horizontal & vertical ridge augmentation with GBR GBR with bone grafting Factors influencing the success of GBR

Contents
Graftassociated new attachment
Classification of regenerative materials Classification of bone graft materials Graft carriers Properties of graft granules Biological mediators incorporated bone grafts

Methods assessing periodontal regeneration

Histology
Direct measurement of bone Probing examination Radiographic examination

Future approach in periodontal regeneration Conclusion References

Introduction
A study by A. Jayakumar, S. Rohini, A. Naveen, et al has shown the following results*. A tooth was considered to have a vertical defect amenable for regeneration when the defect angle was 45 --------Steffensen B, Weber HP. and the intrabony defect depth was 3 mm --------------Persson RE et al.

*A. Jayakumar, S. Rohini, A. Naveen, A. Haritha, Krishnanjeneya Reddy. Horizontal alveolar bone loss: A periodontal orphan. J Indian Society of Periodontology 2010;14:3181-185.

Definitions

Regeneration

----------AAP.

Periodontal regeneration

Repair

----------Cohen RE.

 True periodontal regeneration has been defined as Healing after periodontal treatment that results in the regain of lost supporting tissues including new acellular cementum attached to the underlying dentin surface, a new periodontal ligament with functionally oriented collagen fibers inserting into the new cementum and new alveolar bone attached to the periodontal ligament. (Quintessence int;1998:29:621-630)

True periodontal regeneration is the reformation of a functionally oriented periodontal ligament with collagen fibers inserting in both regrown alveolar bone and reformed acellular cementum over a previously diseased root surface (Periodontol 2000 1999 ; 19;74-86)

Definitions
New attachment is defined as the union of connective tissue or epithelium with a root surface that has been deprived of its original attachment apparatus.

This new attachment may be epithelial adhesion or connective tissue adaptation or attachment and may include new cementum.

Reattachment describes the reunion of epithelial and connective tissue with a root surface ----------Cohen RE.

Definitions
GTR describes procedures attempting to regenerate lost periodontal structures through differential tissue responses and typically refers to regeneration of periodontal attachment. Barrier techniques are used for excluding connective tissue and gingiva from the root in the belief that they interfere with regeneration.

Bone fill is defined as the clinical restoration of bone tissue in a treated periodontal defect. Bone fill does not address the presence or absence of histologic evidence of new connective tissue attachment or the formation of new periodontal ligament

History

The earliest attempt to repair bony defects was reported in the Edger smith papyrus to be around 2000 BC.

Metals were used to manage bony defects at this time.

In 1682 Van Meekren tried xenografts with a reported success.

This was followed by the use of allografts.

History
Immune response to the allografts, surgeons shifted to the use of autografts.

But this of course was faced with the limited availability of donor sites-especially in children-and the risk of morbidity.

By introduction of the mechanism of creeping substitution by Barth, the structure of the substance to close a bony defect was suggested to be osteoconductive.

 Osteoconduction alone may require a long time to heal a defect and the addition of osteoinductive materials are expensive.

Based on the hypothesis put by Dahlin and Nyman et al., the idea of GTR using a barrier membrane technique, emerged.

Wound healing principles

Healing of periodontal surgical wounds has been suggested to differ from other wounds due to several unique features. Factors such as the presence of -multiple, specialized cell types and -attachment complexes -stromal-cellular interactions, -diverse microbial flora and -avascular tooth surfaces complicate the process of periodontal regeneration

 For true periodontal regeneration SCAFFOLDS -Grafts and Substitutes

-Exclusion membranes

CELL BASED MATERIALS

-Fibroblasts, -SC, MSC

GROWTH FACTORS 1. Angiogenic

-FGF, PDGF

2. Signaling
-EMD, BMP

Regenerative techniques
Regenerative periodontics can be subdivided into two major areas: 1. Non-graft-associated new attachment 2. Graft-associated new attachment.

Many techniques combine both approaches.

Trauma from occlusion may impair post treatment healing.

 Systemic antibiotics are generally used after regenerative periodontal therapy.

Case reports have been presented showing extensive regeneration of the periodontal lesions after scaling, root planing, and curettage

Combined with systemic and local treatment with penicillin or tetracycline in combination with other forms of therapy --------Carranza FA, Moskow BS.

Non-Graft-Associated New Attachment

Periodontal reconstruction can be attained without the use of grafts in meticulously treated

Three-wall defects (intrabony defects) and In periodontal and endodontal abscesses ----------Busschopp J, Goldman H, Hiatt WH, Nabers JM.

Removal of junctional and Pocket Epithelium

The presence of junctional and pocket epithelium has been act as a barrier to successful therapy.

Its presence interferes with the direct apposition of connective tissue and cementum, thus limiting the height to which periodontal fibers can become inserted to the cementum ----------Hecker F et al.

Curettage
Results of removal of epithelium by means of curettage vary from complete removal to persistence of as much as 50% -----Smith BA, Echeverri M.

It therefore is not a reliable procedure.

Ultrasonic methods and rotary abrasive stones have also been used, but their effects cannot be controlled because of the clinician's lack of tactile sense.

Chemical agents
Chemical agents have also been used to remove pocket epithelium, in most cases in conjunction with curettage.

The most commonly used drugs have been sodium sulfide, phenol camphor, antiformin, and sodium hypochlorite.

However, the effect of these agents is not limited to the epithelium, and their depth of action cannot be controlled.

Surgical techniques
Excisional new attachment procedure

Consists of an internal bevel incision performed with a surgical knife, followed by removal of the excised tissue -----Yukna RA.

No attempt is made to elevate a flap.

After careful scaling and root planing, 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.

Excellent results have been obtained with this technique in uncontrolled human studies -----------Becker W et al.

The modified Widman flap, as described by Ramfjord and Nissle, is similar to the excisional new attachment procedure but is followed by elevation of a flap for better exposure of the area.

It eliminates the pocket epithelium with the internal bevel incision.

Prevention of Epithelial Migration

Elimination of junctional and pocket epithelia may not be sufficient because the epithelium from the excised margin may rapidly proliferate to become interposed between the healing connective tissue and the cementum.

Several investigators have analyzed in animals and humans the effect of excluding the epithelium by amputating the crown of the tooth and covering the root with the flap (root submergence) -----Bjorn H, Hollender L, Lindhe J. This experimental technique not only excludes the epithelium but also prevents microbial contamination of the wound during the reparative stages.

 Successful repair of osseous lesions in the submerged environment was reported, but obviously this method has little or no clinical application.

Another method proposed to prevent or retard the migration of the epithelium consists of total removal of the interdental papilla covering the defect and its replacement with a free autogenous graft obtained from the palate Ellegaard B, Karring T, Loe H.

During healing, the epithelium necroses, and its migration is retarded.

Coronally positioned (advanced) flaps

Another approach to delaying epithelial migration into the healing pocket area has been the use of coronal displacement of the flap,(Bernimoulin) which increases the distance between the epithelium and the healing area.

This technique is particularly suitable for the treatment of lower molar furcations and has been used mostly in conjunction with citric acid treatment of the roots ---------Gantes BG, Garrett S.

Periodontal regeneration after the use of this technique has been demonstrated histologically in humans.

Biomodification of the Root Surface

Changes in the tooth surface wall of periodontal pockets interfere with new attachment. However, these obstacles to new attachment can be eliminated by thorough root planing.

Several substances have been used in attempts to better condition the root surface for attachment of new connective tissue fibers.
These include citric acid, fibronectin, and tetracycline.

Citric acid (Register & Burdic)

Studies by Urist showed that the implantation of demineralized dentin matrix into muscle tissue in animals induced mesenchymal cells to differentiate into osteoblasts and started an osteogenic process.

Following up on this concept, a series of studies applied citric acid to the roots to demineralize the surface, thus inducing cementogenesis and attachment of collagen fibers.

FIBRONECTIN

Fibronectin is the glycoprotein that fibroblasts require to attach to root surfaces.

The addition of fibronectin to the root surface may promote new attachment -------Busschopp J, De Boever J, Fernyhough W, Page RC.

However, increasing fibronectin above plasma levels produces no obvious advantages.

 The effect of a fibrin-fibronectin sealing system on healing of periodontal surgical wounds, particularly in reconstructive procedures, has been investigated --------Pini Prato G, Clauser C, Cortellini P.

This material is commercially available in Europe as Tissucol.

It is a biologic mediator that enhances the tissue response in the early phases of wound healing, prevents separation of the flap, and favors hemostasis and connective tissue regeneration.

TETRACYCLINE (Frantz and Polson) In vitro treatment of the dentin surfaces with tetracycline increases binding of fibronectin, which in turn stimulates fibroblast attachment and growth while suppressing epithelial cell attachment and migration ----------Alderman NE. It also removes an amorphous surface layer and exposes the dentin tubules ----------Alderman NE.

A human study showed a trend for greater connective tissue attachment after tetracycline treatment of roots, tetracycline alone gave better results than when combined with fibronectin -Alger FA.

Guided tissue regeneration

Biologic foundation Surgical debridement and resective procedures are the traditional surgical treatments used to improve clinical disease parameters and arrest its progression. Minimal regeneration of bone and the tooth supporting structures after these therapeutic treatments --------------Polson AM et al. These methods typically heal by repair, forming a combination of connective tissue adhesion/attachment or forming a long junctional epithelium ----------Caton J, Nyman S.

 The concept of compartmentalization, was developed by Melcher in 1976

In this concept the connective tissues of the periodontium are divided into four compartments
- The lamina propria of the gingiva (gingival corium), - The periodontal ligament, - The cementum, - The alveolar bone.

The final outcome of periodontal pocket healing depends on the sequence of events during the healing stages ---------Melcher AH. If the epithelium proliferates along the tooth surface before the other tissues reach the area, the result will be a long junctional epithelium.

If the cells from the gingival connective tissue are the first to populate the area, the result will be fibers parallel to the tooth surface and remodeling of the alveolar bone with no attachment to the cementum.
If bone cells arrive first, root resorption and ankylosis may occur. Finally, only when cells from the periodontal ligament proliferate coronally, there will be new formation of cementum and periodontal ligament --------Melcher AH.

 From this concept of compartmentalization, GTR procedures developed and barrier membranes were used to accomplish the objectives of epithelial exclusion: cell/tissue repopulation control, space maintenance, and clot stabilization -----Nyman S, Lindhe J, Karring T and Gottlow J.

GTR is based on the exclusion of gingival connective tissue cells and the prevention of epithelial down growth into the wound.

By exclusion of these tissues, cells with regenerative potential (periodontal ligament [PDL], bone cells, and possibly cementoblasts) can enter the wound site first and promote regeneration.

Membrane design
There are five criteria considered important in the design of barrier membranes used for GTR. ----------Greenstein G, Caton JG, Hardwick R et al

These include biocompatibility, cellocclusiveness, space making, tissue integration and clinical manageability.

Various types of materials have been developed, which can be grouped together as either non-resorbable or resorbable membranes.

Membranes used for GTR

Classified by Minabe (1991)

Non-resorbable

Resorbable

Classification by Gottlow (1993)

1. First generation (non-resorbable) Millipore filter Expanded polytetrafluoroethylene (ePTFE) membrane (GORE-TEX) Nucleopore membrane Rubber dam 2. Second generation (resorbable) Porcine collagen membrane (BioGuide) Polylactic acid membrane (Guidor) Vicryl mesh (Polyglactin 910) Cargile membrane Oxidised cellulose Hydrolyzable polyester Polyglycolic acid, polylactic acid & trimethylene carbonate (Osseoquest) Polylactic acid gel (Atrisorb) Bovine Achilles tendon collagen (BioMend) Bovine collagen

3. Third generation (resorbable with growth factors) Being developed

Another classification(generations) 1. Non-resorbable 2. resorbable 3. Collagen resorbable membrane 4. Synthetic resorbable membranes 5. Amniotic membrane & fibrin glue

Non-resorbable membranes
The first membranes used experimentally by Nymans group in their initial work were constructed from Millipore (cellulose acetate) filters. As this technique became more prevalent, the first commercial membrane was produced from Teflon (e-PTFE). This membrane consisted of 2 parts: a collar portion, having open pores to allow in-growth of connective tissue and to prevent epithelial migration; and an occlusive portion, preventing the flap tissues from coming into contact with the root surface ------------Scantlebury TV. This membrane is the gold standard of GTR and GBR treatments.

 The nonresorbable membranes required a second operation, albeit frequently very simple, to remove it.

This second operation was done after the initial stages of healing, usually 3 to 6 weeks after the first intervention.

The ePTFE membrane (nonresorbable) can be obtained in different shapes and sizes to suit proximal spaces and facial/lingual surfaces of furcations

 After 4 to 6 weeks, the margin of the membrane becomes exposed. The membrane is removed with a gentle tug 5 weeks after the operation.

If it cannot be removed easily, the tissues are anesthetized and the material is surgically removed using a miniflap.

The results obtained with the guided tissue regeneration technique are enhanced when the technique is combined with grafts placed in the defects. ------Blumenthal NM, Steinberg J, Lekovic Vet al.

Non resorbable membrane are available in four configuration

1. 2. 3. 4.

Wrap around Interproximal Single tooth wide Single tooth narrow

Resorbable membranes
There are two types of biologically resorbable membranes: 1). Polyglycoside synthetic copolymers: polylactic acid (Guidor) polyglactide and polylactide (Resolute), polyglactin 910 (Vicryl); 2) Collagen. Collagen membranes share in common with all resorbable membranes the fact that they do not require a second surgery for retrieval. This saves time and cost and is greatly appreciated by patients. Collagen is the principal component of connective tissue and provides structural support for tissues throughout the body. ------ Wang HL, Carroll MJ.

 The potential of using autogenous periosteum as a membrane and also to stimulate periodontal regeneration has been explored in two controlled clinical studies, one of grade II furcation involvements in lower molars and another of interdental defects ---------Kwan SK, Lekovic V et al.

The periosteum was obtained from the patient's palate by means of a window flap.

Both studies reported that autogenous periosteal grafts can be used in guided tissue regeneration and result in significant gains in clinical attachment and osseous defect fill.

 Degradation of resorbable membranes is accomplished by various mechanisms present within the periodontal tissues.

The primary structural component of most commercially available collagen membranes is type I collagen, which is degraded by endogenous collagenase into carbon dioxide and water.

Crosslinkage of collagen fibers can affect the rate of degradation -------- Minabe M et al. Cross-linking is a laboratory modification of the collagenous matrix designed to stabilize the collagen fibers and maintain the integrity of the membrane after placement --------- Charulatha V, Rajaram A.

 Using a collagen membrane for horizontal ridge augmentation

Amniotic membrane
Another resorbable membrane is the amniotic membrane.

Petti Gustavo has been the first one who have had a new attachment: guided tissue regeneration using an amniotic membrane and fibrin glue.

Amniotic membrane is a composite membrane consisting of pluripotent cellular element embedded in a semi permeable membranous structure.

 It has been shown that amniotic membrane is an immunotolerant structure.

The existence of pluripotent stem cells possessing the ability of transdifferenciation to other cellular elements of periodontium makes it a suitable candidate for GTR.

Excellent revascularization of this membrane is the another favorable property.

Objectives of an ideal barrier membrane

1. It should be bio compatible &/or allow tissue integration.

2.
3. 4.

It should be non toxic & non carcinogenic.

It should be chemically inert & non antigenic. It should be easily sterlizable.

5.
6.

It should be easy to handle during surgery

It should be sufficiently rigid so as to maintain a space b/w it & the root surface.

7. It should be supplied in different design to suit the specific clinic situation. 8. It should be easily stored & should have a long shelf life. 9. It should be easily retrievable in case of complication. 10. It should not be too expensive.

COMPLICATIONS

Membrane exposure constitutes the major complication associated with GTR, with prevalence between 50% and 100% ---------Selvig KA,Cortellini P, Pini Prato G, Mayfield L et al.

The introduction of novel access flaps specifically designed to preserve the interdental tissues ------------- Tonetti MS, Cortellini P et al. and the use of bioabsorbable membranes have led to a slight reduction in the prevalence of membrane exposure.

Other postoperative complications, including bleeding, swelling, hematoma, erythema, suppuration, sloughing or perforation of the flap, membrane exfoliation, and postoperative pain, have been reported in the immediate postoperative period -------------Murphy KG.

Infectious aspects of periodontal regeneration

Microbiota of failing periodontal regeneration Oral bacteria have a propensity to colonize barrier membranes.

Wang et al. compared the in vitro attachment of 15 oral microorganisms to ePTFE, polyglactin 910 and collagen barrier membranes.
Streptococcus mutans revealed the strongest attachment in all experiments except for Porphyromonas gingivalis, which exhibited higher cell counts on collagen membranes.

Ricci el al. also showed the in vitro ability of P. gingivalis to penetrate barrier membranes from one side to the other.

Simion et al. reported that an ePTFE barrier membrane had to be exposed for at least three weeks for complete bacterial penetration.

Using scanning electron microscopy, Selvig et al. identified cocci, filaments and short curved rods in the outer and inner surfaces of retrieved barrier membranes.

 The patients had been prescribed tetracycline for 2 weeks post surgically and chlorhexidine rinses during the period of membrane insertion.

Selvig et al. showed an inverse relationship between the extent of barrier membrane microbial contamination and gain in clinical attachment level.

 Nowzari & Slots demonstrated an inverse relationship between microbial counts on ePTFE barrier membranes and gain of probing attachment.

Mombelli et al. recovered specific bacterial species from barrier membranes retrieved from periodontal sites showing 15 mm gain in clinical attachment.

The patients performed strict plaque control and rinsed with chlorhexidine but received no systemic or topical antibiotic therapy.

Anti-infective therapy in periodontal regeneration

Anti-infective therapy in periodontal regeneration includes

-Mechanical debridement -Local or systemic delivery of antimicrobial agents, -Possible application of slow-release antimicrobial agents to the barrier membrane material -Proper oral hygiene measures by the patient.

As discussed by van Winkelhoff et al. systemic antimicrobial therapy may be necessary to suppress A. actinomycetemcomitans and other periodontal pathogens in the human oral cavity.

Systemic administration of amoxicillin-clavulanic acid (Augmentin) Nowzari H et al. .and ornidazole Mombelli A et al. have demonstrated clinical benefits in regenerative periodontal therapy.

Metronidazole and ciprofloxacin exhibit synergy and constitute a valuable drug combination for periodontitis patients with anaerobic pathogens together with superinfecting enteric bacteria ---------Rams TE, Slots J et al.

 Antimicrobial coating of barrier membranes constitutes a novel approach to controlling membrane associated infections.

Harvey et al. have described the potential of antibiotic bonding to PTFE by means of the cationic surfactant, tridodecylmethylammonium chloride (Polysciences, Inc., Warrington, PA, USA).

Nowzari H et al. has studied the clinical benefit of applying tetracycline- HC1 to the surface of ePTFE membranes

 In vitro studies showed that, despite exhaustive washing, the tetracycline coated barrier membranes released biologically active tetracycline for 3-6 weeks.

Tetracycline coated barrier membranes harbored significantly fewer cultivable pathogens for the first 2 weeks after membrane insertion than non-coated membranes ---------- Nowzari H et al.

Also, after 6 weeks, tetracycline-coated membranes were associated with more gain in clinical attachment than non-coated membranes ---------- Nowzari H et al.

GBR
Four methods have been described to increase the rate of bone formation and to augment bone volume:

1. osteoinduction using appropriate growth factors, 2. osteoconduction where a grafting material serves as a scaffold for new bone growth,

3. distraction osteogenesis by which a fracture is surgically induced and the two fragments are then slowly pulled apart
4. guided bone regeneration (GBR) which allows spaces maintained by barrier membranes to be filled with new bone. -------------Dahlin C, Lindhe A, Gottlow J, Nyman S.

 GBR is based on principles of guided tissue regeneration (GTR) ----------Nyman S, Karring T et al. Dahlin and colleagues spearheaded early research on GBR.

In 1988, Dahlin et al. published the results of animal experimentation on the healing of bone defects.

Statistical analysis of the healed sites demonstrated a highly significant increase in bone regeneration on the membrane side as compared to the control.

Principles of guided bone regeneration To achieve better clinical outcomes, the GBR barrier should possess the following properties: ------------------Wang HL, Carroll MJ. Scantlebury criteria

Cell exclusion Tenting Scaffolding Stabilization Framework

 Study by Buser et al. was one of the first to report successful ridge augmentation with GBR in humans using an e-PTFE membrane and tenting pins.

The gain in new bone formation ranged from 1.5 to 5.5 mm.

 Acellular dermal matrix allograft (Allo-DermTM) has been used in periodontal, plastic and reconstructive surgery since 1994.

Alloderm may be used for soft tissue augmentation procedures around dental implants without using the patient's own palate to procure the donor tissue ------------Silverstein LH, Ccllon DP.

In addition, the unlimited supply, color match, and thickness, as well as no degradation if primary closure is not achieved, and formation of additional attached gingiva makes this material a good choice for membrane barrier techniques.

 Using Alloderm for GBR without primary closure

Horizontal and vertical ridge augmentation with GBR

With introduction of GBR technique, combination of block grafts with bone fillers and membranes was applied.

The first membrane used for horizontal ridge augmentation was ePTFE.

But because of the increased risk of complications following wound dehiscence, resorbable collagen membrane was introduced --------Aghaloo TL, Moy PK.

 Wang and Boyapati proposed the PASS principles for predictable bone regeneration in 2006.

To attain horizontal and/or vertical bone augmentation beyond the envelope of skeletal bone, four principles are needed to be met:

P-primary wound closer A-angiogenesis S-stability of blood clot S-space maintenance.

Conclusion

The future of the regeneration may depend on the merging of various technologies and biological concepts, including the possible use of biological barriers, various bone and periodontal growth inducers, and artificial matrices that will attract or carry the cells necessary for regeneration.

References
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