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![• Charles Anderegg et al 1999…bioactive glass
has an additive effect in improving clinical
parameters such as the PD and defect fill in G-
II furcations compared to OFD [weighted mean
difference: 0.60 mm].
• Treatment of intraosseous defects …
improvement of the bony lesion when compared
to the OFD. Weighted mean difference in CAL
gain between bioactive glass and OFD was 1.04
mm.](https://image.slidesharecdn.com/bonegrafts2-241013013219-01e1acdf/75/Bone-Grafts-USE-IN-PERIODONTOLOGY-2-pptx-21-2048.jpg)
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Bone Grafts USE IN PERIODONTOLOGY 2.pptx
- 1.
- 2. Contents • Polymer basedbone graft substitutes – Hard tissue replacement (HTR) composite – Polylactic acid & polyglycolic acid – Coralline calcium carbonate – Bioceramic grafts • Hydroxyapatite • Tricalcium phosphate • Bioactive glass • Morphological and biological implications • Technical implications • Healing following grafting • Grafts in combination with other procedures • Conclusion • References
- 3. • Perioglas • Biogran •Hench et al 1980 • Composed of elements …silicon dioxide (46 mole %), sodium oxide (24.4 mole %), calcium oxide (26 mole %), and phosphorous pentoxide (6 mole %). BIOACTIVE GLASS
- 4. • Pore size-90-710 µm. • Bonds to bone as well as soft tissue • When exposed to tissue fluids … covered by a double layer composed of silica gel & calcium phosphorous rich (apatitie) layer adsorption and concentration of proteins used by osteoblasts to form a mineralized ECM (El-Ghannam et al 1997) • These properties guide & promote osteogenesis rapid bone formation Perioglass
- 6. • Osteoconductive • Osteostimulative •Local hemostatic effect. • Resorbable – …6 months. • Completely biocompatible – …rejection. • 100% synthetic – …disease transmission. • 100% absorbable …better/faster bone formation. Advantages
- 7. • Antimicrobial/antibacterial/anti- inflammatory. • Requiresno special mixing equipment or surgical technique. • Adheres to instruments …insertion. • Contours easily to the shape of the defect. • Its positively charged particles adhere to the defect site so it does not float out…
- 8. • Schepers andDucheyne (1997). • …bone repair not …also by cellular differentiation in the internal chamber of the particles through the active stimulation of osteoblast proliferation and differentiation as evidenced by increased levels of DNA synthesis & osteocalcin and alkaline phosphatase. Osteostimulation (controlled induction)
- 9. • Through anionic exchange, Bioglass first acts as a scaffolding around and through which new bone forms. • …active deposit of osteoid matrix directly on the surface of the particles. • These areas of new bone formation can act as nuclei … • "controlled induction“…. capacity of an osseoconductive material to stimulate new bone deposition on its surface.
- 11. • …decrease clottingtime in lab tests by 25%. • causes – development of a positive surface charge – the release of calcium ions during material dissolution. • A positive surface charge has been shown to encourage clotting in a number of models. Hemostatic
- 12. • calcium ions…intrinsicand extrinsic clotting pathways, …in maturation of the fibrin network developed during clotting. • The continued physical presence of the PerioGlass particles stabilizes the fibrin clot …more rapid site vascularization and provide an active scaffold for tissue repair.
- 13. • inflammatory responsecan reduce local pH to 5.5 …release of various enzymes during phagocytosis. • The acidic pH - damaging to the surrounding tissues …stimulating new inflammatory reactions…prolong the healing process. • …leaches cations into the surrounding tissues, negates the acidic pH …decreases the inflammation. Anti-inflammatory
- 14. • In vitrotests …3-5-log reduction …. • This bactericidal effect – increase in pH, causing an osmolytic effect on the bacterial cell wall. Antimicrobial
- 15. • Karatzas etal (1999)., in a histologic study in monkeys, reported that the greatest contributions of a bioactive glass – – incorporation into the connective tissue, – formation of a new insertion and – inhibition of apical migration of the junctional epithelium. Inhibition of long junctional epithelium
- 16. • The collagenthat attaches to the bioactive glass surface …extends apically to the junctional epithelium, … • Its superficial bioactivity may stimulate a rapid formation of a connective tissue seal - ability to block the epithelium migration and allow for repopulation of the previously contaminated area by periodontal ligament cells.
- 17. • However, Nevinset al. (2000) observed healing by long junctional epithelium in intrabony defects … humans. • Henrique et al 2005 - showed an inhibitory property on the apical migration of the junctional epithelium. • …sites treated with the bioactive glass, the junctional epithelium migrated apically to the level of the particles most coronally located inside the defect, not surpassing this point.
- 18. • narrower rangeof particle sizes of 300-355µm, …advantageous for guiding osteogenesis • Formation of hollow calcium phosphate growth chambers occurs with this particle size … phagocytosing cells can penetrate the outer silica gel layer by means of small cracks in the calcium phosphorous layer and partially resorb the gel. Biogran
- 19. • This resorptionformation of protective pouches where osteoprogenitor cells can adhere, differentiate and proliferate. • larger particles – do not resorb in the same manner…slows the healing process theoretically because bone-healing progress from the bony walls of the defect • smaller particles – cause a transient inflammatory response…retard the stimulation of osteoprogenitor cells.
- 20. • In theory,it would appear that Biogran has a clinical advantage over Perioglass, which has multiple particle sizes. • Clinically, no comparisons have been made … • A human study by Schepers et al (1994) … Biogran could be used successfully in the treatment of osseous defects.
- 21. • Charles Anderegget al 1999…bioactive glass has an additive effect in improving clinical parameters such as the PD and defect fill in G- II furcations compared to OFD [weighted mean difference: 0.60 mm]. • Treatment of intraosseous defects … improvement of the bony lesion when compared to the OFD. Weighted mean difference in CAL gain between bioactive glass and OFD was 1.04 mm.
- 22. • Meta-analysis ofchange in bone fill revealed a greater, although not significant, increase (1.61 mm) for bioactive glass than for OFD. • Meta-analysis also showed that bioactive glass resulted in significantly greater PD reduction than the OFD procedure (Wilson & Low 1992) • Nevins et al (2000) found decreased PD of 2.7mm and 2.2mm of CAG …and the healing was by long junctional epithelium with no histological evidence of periodontal regeneration.
- 23. Evaluation of alloplasticmaterials • Histologic evidence …may lead to periodontal regeneration in humans is lacking and animal experiments have failed to demonstrate regeneration of a functional periodontium following implantation …(Barney 1986). • Bioactive glasses show better clinical results than HA and TCP .
- 24. • Alloplasts mayhave their greatest usefulness as autograft extenders… to provide a sufficient total volume of graft material. • They may also be used as carriers …. • AAP World Workshop - … function primarily as defect fillers. If regeneration is the desired treatment out-come, other materials are recommended.
- 25. • Resorption andreplacement phenomenon of bone grafts depends on the morphology i.e particle size and shape & the influence of interparticulate space on infiltration of vascular cellular elements and bone formation. • Too large in size – resorb at a slower rate – reduced surface area MORPHOLOGIC AND BIOLOGIC IMPLICATIONS OF BONE GRAFTS
- 26. • Too smallin size – induce inflammation, – be readily resorbed or phagocytosed – result in an decreased interparticulate space. • Thus, to support trabecular bone ingrowth, the pores …at least 40 to 100 µm, • to support osteonal bone ingrowth, pores …. at least 100 µm. (Klawitter et al 1971)
- 27. • Human periodontalligament fibroblasts were grown on a variety of bone replacement grafts… differences in cell binding and spreading as a function of the bone replacement graft substrata. • SEM - adherence dynamics varied among BGs, with cell spreading occurring most rapidly on materials derived directly from bone. • Cell spreading was slower on non-osseous HAs and other synthetic surfaces (Moses et al 1996)
- 28. • Evaluation ofthe time course of cell spreading … fibroblasts cultured on PepGen P-15 spread as rapidly as those seeded onto bone of human origin. • …addition of P-15 to bone replacement graft surfaces may enhance binding of periodontal ligament fibroblasts during the early stages of wound repair (Moses et al 1996)
- 29. Technical implications • successrates …enhanced by – appropriate selection of a defect configuration that is amenable to grafting and – following a thorough surgical technique.
- 30. Critical procedures thatmay enhance clinical outcomes • Preparation of graft material – sterile water or saline - hinder vascular infiltration... • Promotion of a bleeding surface – accomplished by proper defect debridement – walls are relatively dry, and/or glistening, healing may be enhanced by intramarrow penetration to encourage bleeding and allow the ingress of reparative cells, vessels and other tissues.
- 31. • Presuturing – Looseplacement of sutures, left untied, prior to the filling of the defect reduces the possibility of displacing … – Alternative - Vertical mattress sutures that pass over the incision
- 32. Adequate condensation ofgraft material • …placed in small increments…. sterile plastic or Teflon- lined amalgam carriers • sterile amalgam squeeze-cloths used over the suction tip to dry the defect without removing … • Small increments …, gently packed into the angles and base of the defect with small pluggers or curettes and dried … • The process is repeated until the defect is filled
- 33. Fill to arealistic level • …only to the level of the defect walls • Overfilling may actually be counterproductive …may preclude proper flap closure… retarding healing & loss of the graft material.
- 34. Achievement of tissuecoverage • primary closure with replaced flaps and contact of the interproximal papillae… • …not satisfactory, additional releasing incisions and/or flap reflection may be necessary. • …use of an autogenous free gingival graft, freeze-dried skin or dura mater allograft, or collagen barrier to cover the bone graft site.
- 35. Placement of aperiodontal dressing • The use of a firm, protective periodontal dressing for ten days … – possible impingement of foreign materials into the graft site, – flap displacement and – loss of the material • that would jeopardize the success of treatment
- 36. Administration of antibiotics •Tetracyclines…(Nassr et al 1999) • for immediate post-surgery plaque suppression – broad spectrum of activity, – attraction to healing wound sites, and – concentration in GCF. • They may be administered in therapeutic doses for the first 20 days post-surgery or until the patient can practice proper plaque control in the area.
- 37. Healing of bonereplacement grafts • Bone is formed in response to graft materials in overlapping phases. • Revascularization is initiated within the first few days …. Blood vessels originating from host bone invade the graft. A pore size of 100- 200 m is very conducive to vascular invasions
- 38. • …incorporation ofgrafted bone particles by new bone cells from host. Osteogenesis, osteoinduction, osteoconduction. • As a graft is being incorporated, it is gradually resorbed and replaced by new host bone. This process is sometimes referred to as “creeping substitution”. • The final phase of healing is bone remodeling.
- 39. Long term outcomesof bone grafts • Fleming et al 1998 compared 6 month vs 36 month CAL recordings. A 0.12mm gain was observed for the test procedure and 0.43mm decrease for control procedure. • Galgut et al 1992 assessed 42 month CAL. A 0.27mm decrease for the grafted group and 0.14 mm gain for the OFD group was observed.
- 40. • A longterm evaluation of HA graft compared to OFD showed that 40% OFD defects lost attachment over 5 year follow up, whereas 2/3rds of the HA defects gained attachment over the same interval. (Yukna et al 1989)
- 41. Patient centered outcomes •Insufficient data exists for comparison of patient outcomes of different grafts. • In most of the studies no adverse effects were observed. • …Pebbled surface structure of grafted site, transient slight gingival inflammation, delayed soft tissue healing, and exfoliation/shedding of the implanted biomaterial.
- 42. Grafts in combinationwith other procedures • GTR • Varying results …combining non-resorbable membranes with bone grafts in treating furcation defects. • McClaine et al 1993 - complete furcation closure in sites using membrane + DFDBA. All the grafted sites remained stable after 5 years, whereas less than half of only membrane sites did.
- 43. • Intrabony defects– one uncontrolled study (McClaine et al 1994) showed substantial gain in CAL and PD reductions when ePTFE membranes + DFDBA. • Yet two controlled trials failed to show significant differences. (Guilleman et al 1993, Mellado et al 1995)
- 44. • Root conditioning •Because altered root surface can inhibit regeneration and new attachment, some studies have investigated the use of citric acid or tetracycline root conditioning as an adjunct to GTR and grafting procedures. Although animal studies have shown good results, human trials are controversial.
- 45. • In reviews…Schallorn et al and Garrett et al …evidence seems to indicate that when both furcation and intraosseous defects are treated with ePTFE barriers addition of bone grafts may improve clinical results including bone fill and clinical parameters. • Stahl et al reported histologic evidence of limited cementogenesis in two of four defects treated with both GTR and DFDBA.
- 46. CONCLUSION OF SYSTEMATICREVIEW ON THE EFFICACY OF BONE REPLACEMENT GRAFTS • Treatment of intrabony defects – BGs increase bone level, reduce crestal bone loss, increase CAL and reduce probing depth compared to OFD – No differences in clinical outcome measures emerged between particulate bone graft and calcium phosphate (hydroxyapatite) ceramic grafts. – BGs in combination with barrier membranes increase CAL and reduce PD compared to graft alone.
- 47. • Treatment offurcation defects – In spite of insufficient studies of comparable design being available to submit data to meta-analysis, outcome generally indicated positive clinical benefits with the use of grafts in the treatment of Class II furcations.
- 48. • Histological outcomeparameters – Two RCTs …DFDBA supports the formation of a new attachment apparatus in intrabony defects, whereas OFD resulted in periodontal repair … long junctional epithelium. – Multiple observational studies provide consistent histologic evidence that autogenous grafts & DFDBA support the formation of new attachment apparatus.
- 49. – In contrast,all available data indicate that alloplastic grafts support repair rather than regeneration. – Apart from polylactic acid, the use of grafting procedure produces a greater CAL gain and bone fill when compared to the OFD procedure. – A greater probing depth reduction is also generally observed with graft biomaterials.
- 50. CONCLUSION • Although Bonegrafts have been shown to be efficacious …the reconstruction appears to be limited to a mean bone fill of approx. 3 mm irrespective …. • Formation of a new attachment apparatus … using bone and bone substitutes, is still a matter of debate.
- 51. • When consideringthe adjunctive effect of reconstructive procedures, – evaluation of adverse effects related to the additional use of biomaterials/biological agents , – post operative complications, – ease of maintenance, – change in esthetic appearance, – estimation of patient well-being and – cost/benefit ratio • should be considered.
- 52. • The ultimategoal of periodontal therapy is to reverse the disease process and completely regenerate the periodontium. Additional techniques to enhance the regenerative process clearly are needed. • Multiple histologic reports suggest that regeneration of a new attachment apparatus is possible with different types of autogenous & alloginc bone grafts.
- 53. • Bone allograftsare safe for human use if proper exclusionary techniques and processing are employed. • Bone allografts and alloplasts offer similar advantages with respect to bone fill • Synthetic bone grafting materials offer promise in periodontal therapy, but they are far from a panacea.
- 54. • They arenot better clinically …. • All graft materials are only one aspect of the treatment of infrabony periodontal defects. • More important than the type of graft material is proper case selection and appropriate surgical management of the defect and the root surface. • There is no synthetic substitute for properly performed periodontal surgery.
- 55. • Clinical Periodontics:Carranza, 10th edition. • Periodontal Regeneration: Alan M Polson • Bone and bone substitutes Hishamf. NASR, Mary Elizabetha Ichelmann- Reidy & Raymonda . Yukna: Periodontology 2000: V0l. 19, 1999, 74-86 • Svnthetic bone grafts in periodontics Raymond A . Yukna Periodontology 2000, Vol. 1. 1993, 92-99 • Which reconstructive procedures are effective for treating the periodontal intraosseous defect? Leonardo Trombelli. Periodontology 2000, Vol. 37, 2005, 88–105 • Freeze dried allografts in periodontal reconstructive surgery James Mellonig. DCNA Vol 35, No.3 July 1991 References
- 56. • Alloplastic materialsin periodontal reconstructive surgery Vivek Shetty & Thomas Ilan. DCNA Vol 35, No.3 July 1991 • Biologic and clinical considreations for autografts & allografts in periodontal regeneration therapy. Edwin Rosenberg et al DCNA Vol 42.no.3,July 1998 • Periodontal Regeneration Techniques for Treatment of Periodontal Diseases. Hom-Lay Wang, Jason Cooke. Dent Clin N Am 49 (2005) 637–659 • Bioactive Glass Efficacy in the Periodontal Healing of Intrabony Defects in Monkeys; Braz. Dent. J. vol.16 no.1 • Periodontal Therapy:Clinical Approaches and Evidence of Success Myron Nevins, James T Mellonig
- 57. • The efficacyof bone replacement grafts in the treatment of periodontal osseous defects. A systematic review. Mark Reynolds et al. Ann Periodontol, Vol 8, No 1, Dec 2003; 227-265 • Biomaterials used as bone graft substitutes. S. Narang, V. Chava. Annal Dent Univ Malaya 2000; 7: 36-42. • Autogenous and Allogeneic Bone Grafts in Periodontal Therapy. James T. Mellonig. Critical Reviews in Oral Biology and Medicine, 3(4):333-352 (1992) • Periodontal therapy. Dragoo M.R • Contemporary Periodontics. Robert Genco • Periodontics. Daniel Grant
- 58.
- 59. The Process A chemicalreaction between the particles and body fluids creates an environment favorable for rapid creation of new bone Irregular shapes and varied particle sizes provide framework for attachment of bone tissue The end result is complete regeneration of normal bone and virtually total resorption of graft material