Regenerative osseous surgery

 The ultimate goal of periodontal therapy is the
complete restoration of the structure and function
of diseased periodontal tissues. Regeneration of
periodontium is considered to be an essential part
of current mode of periodontal treatment
approach.

Therapeutic bone regeneration approaches
uses the principles of osteogenesis, osteoconduction and
osteoinduction.
 Osteogenesis: The direct transfer of vital cells to the area
that will regenerate new bone.
 Osteoconduction: Embraces the principles of providing the
space and a substratum for the cellular and biochemical
events progressing to bone formation.
 Osteoinduction: Embodies the principle of converting
pluripotential , mesenchymal derived cells along the
osteoblasts pathway with subsequent bone formation.

Clinical methods:
It consists of comparisons between pretreatment and
post treatment pocket probings and determination of
clinical gingival findings. Probe can be used to
determine pocket depth, attachment level and bone
level.
Radiographic methods:
It allows assessment of the bone tissue adjacent to
the tooth. A comparative study of pretreatment bone
level and post therapy bone fill with 12 month reentry
bone measurement showed that linear radiographic
analgesics significantly underestimates pretreatment
bone loss and post treatment bone fall.

Recent radiographic evaluation methods are:
 Substraction radiography
 CADIA (Computer Assisted Densitometric Image
Analysis)

Surgical re-entry:
Surgical reentry of a treated defect after a period
of healing can provide a good view of the state of
the bone crest that can be compared with the view
taken during the initial surgical intervention.
This method is very useful but has two
shortcomings: It requires a frequently unnecessary
second procedure and it does not show the type of
attachment that exists.
Histologic methods:
Type of attachment can be determined by
histological analysis of tissue blocks.

NON BONE GRAFT ASSOCIATED PROCEDURES
Removal of junctional and pocket epithelium
Its presence interferes with the direct
apposition of connective tissue and cementum, thus
limiting the height to which periodontal fibers can
insert to the cementum. Methods to remove
junctional and pocket epithelia are
 Curettage: Use of ultrasonic methods, lasers, rotary
abrasives.
 Chemical agents: Sodium sulphide, phenol camphor,
Antiformin and NaOCl.
 Techniques: Recommended one

Prevention or impeding of epithelial migration:
Two methods:
 One consists of total removal of the interdental
papilla covering the defect and its replacement
with a free autogenous graft obtained from
palate.
 Second approach is the use of coronally
displaced flaps, which increase the distance
between the epithelium and healing area.

Clot stabilization, wound protection and space creation:
Some investigators have attributed the
successful results reported with graft materials, barrier
membranes and coronally displaced flaps to the fact that
these techniques protect the wound and create a space
for undistributed and stable maturation of the clot.
Biomodification of the root surface:
Changes in the tooth wall offers periodontal pockets
interfere with new attachment. Several substances have been
used in attempts to better condition the root surface for
attachment of new connective tissue fibers. They are:
 Citric acid
 Fibronectin
 Tetracycline

Polypeptide growth factors
 Growth factors are polypeptide molecules released by
cells in the inflamed area that regulate events in
wound healing. They regulate C.T migration and
proliferation and synthesis of protein and other
components of the extracellular matrix.
 They are recreated by macrophages,
endothelial cells, fibroblasts, platelets etc..
Enamel matrix proteins
 They are believed to favour periodontal regeneration.
Enamel matrix proteins that are derived from …..teeth
with trade name ‘Emdogain’ can also be used for
periodontal regeneration.

 GTR is the term used to define procedures wherein
regeneration of lost periodontal structures is
sought via selective cell and tissue reproduction of
the periodontal wound (AAP 1992)

 The principle of GTR is based on exclusion of epithelial
and gingival connective tissue cells from the healing area
by the use of a physical barrier that may allow (guide)
periodontal ligament cells to repopulate the detached
root surface where they can regenerate a new attachment
or new attachment apparatus.

 First generation membranes
These are non absorbable membranes
 Second generation membranes
These are bio absorbable or bio degradable
membranes.
 Third generation membranes
These are first and second generation membranes
with adhesion molecules and growth factors.

Bio absorbable membranes:
 Guidor
 Resolute
 Vicryl
 Atrisorb
 Biomend
 Perioguide
 Periogen
Non absorbable membranes
 Silicon sheets
 Cellulose outate lab filters
 Millipore filters
 Polytetrafluroethylene (PTFE) membrane
 Rubber dam

 Bio compatible: it should not elicit an immune response that
interferes with healing
 Stabilization of the blood clot: it should stabilize the blood
clot as it acts as a reservoir of precursor cells required for
regeneration.
 Cell occlusiveness: it should act as barrier for certain cells
that prevent regeneration.
 Space maintenance: it should provide space for ingrowth of
cells potential for regeneration from adjacent periodontal
ligament.
 Tissue regeneration
 Ease of use: it should be easy to trim and place in the defect
site
 Biological activity

 Step I: A full thickness of mucoperiosteal flap should
be reflected 2-3 mm beyond the defect. Vertical
incision should be given where ever necessary.
 Step II: Debridement of osseous defect and curettage
of the inner surface of the flap.
 Step III: Root planning followed by root conditioning
of the exposed root surfaces should be
accomplished.
 Step IV: Create fresh bleeding at the defect site to
allow progenitor cells to progress from bone to the
site.

Step V: The membrane should be trimmed so that it
extends 2-3 mm beyond the margins of the defect in all
directions. Trimming of the flap should also permit primary
tension- free closure of the flap.
Step VI: The membrane should be adapted to the site and
stabilized with the help of suture or tacks.
Step VII: Suture the site with silk suture to obtain tension
free primary closure. Dressing may be considered to
enhance patient comfort but it should not displace or
collapse the graft.
Step VIII: Post operative instructions and antibiotics should
be given.
Step IX: If non-re absorbable membrane is used, it should
be removed after 4-6 weeks.

It is a process which aims at obtaining new attachment
by conditioning the root surface with the help of agents
known as root bio modifiers.
Root bio modification can be done with the help
of the following:
 Chemical treatment of root surface Acid etching (Citric
acid and tetracycline) Detergents (cetylpyridinium chloride
and Na N- lauroylsarcosine)
 Chelating agents: ethylene diamine tetra acetic
(EDTA)acid.
Enzymes Attachment proteins (fibronectin and growth
factors)
 Mechanical
 Lasers

 It is used at a pH of 1 for 2-5 minutes
 It removes smear layer of microcrystalline debris and
eliminates endo toxins and bacteria from root-planned
surface.
 It exposes the dentinal tubules that appear wider with
funnel shaped orifices.
 An early fibrin leakage occurs to the exposed collagen
fibers which prevents the migration of epithelial cells on the
treated root surfaces.
 It accelerates healing and promotes formation of new
attachment by enduring cementogenesis and attachment of
collagen fibers.

 It is used at concentration of 24% at pH 7.
 It exposes the collagen fibers of the dentine matrix.
 It improves clot organization, retards epithelium
growth and enhances clinical attachment gain.
 EDTA has advantage over citric acid as it acts at
neutral pH unlike citric acid that necrotizes the
surrounding periodontal tissues.

 It is a glycoprotein and acts as an adhesive for the
attachment of fibroblast on root surfaces.
 Promotes connective tissue attachment and bone
regeneration
 Prevents the separation of flap and favours
hemostasis
 Prevents the migration and proliferation of epithelial
cells
 Commercially available: tissucol and tisseel

TETRACYCLINE:
 It removes the smear layer and
exposes the dentinal tubule
 It decreases the epithelial cell
attachment
 It also reduces the gingival
collagenolytic activity
GROWTH FACTORS:
 Naturally occurring polypeptide
molecules secreted by macrophages,
endothelial cells, fibroblasts and
platelets.
 They regulate C.T cell migration and
proliferation of periodontal ligament
cells, differentiation of osteoblasts
and cementoblasts and production
of extracelluar matrix proteins.

ENAMEL MATRIX PROTEIN
 Enamel matrix proteins mainly
amelogenin are secreted by Hertwig
epithelial root sheath during tooth
development.
 They induce a cellular cementum
formation and therefore play a role
in in periodontal regeneration.
 It is osteopromotive not
osteoinductive as it stimulates bone
formation when combine with freeze
dried bone allograft.

 It promote cell spreading and bone cell attachment
and differentiate immature bone cell into mature
cell that form new bone.
 It consists of proteins such as Amelogenin(90 %),
Proline rich non Amelogenin, Tuftlin and tuft
protein, serum protein, Ameloblastin, Amelin.
 It is commercially available as Emdogain derived
from developing procaine tooth approved by U.S
Food & Drug Administration.
 It is available as viscous gel.

PROCEDURE
 Raise a flap for regenerative purpose.
 Remove all granulation tissue and tissue tags,
exposing the underlying bone and remove all root
deposit by hand, Ultrasonic scaling or both.
 Completely control bleeding within the defect.
 Demineralise the root surface with Citric acid pH 1.
This removes the smear layer and facilitates
adherence of Emdogain.
 Rinse the wound with saline and apply the gel to
fully cover the exposed root surface. Avoid
contamination with blood or saliva.
 Close the wound with sutures. Perfect abutment of
the flap is necessary.

 Bone grafting is a surgical procedure by
which new bone or a replacement material is
placed into spaces between or around broken
bone (fractures) or defects to aid in healing.

Autograft:
 Extraoral – lip marrow
Fresh
Frozen
 Intraoral
Osseous coagulum
Bone blend
Tuberosity
Extraction sites
Continguous autografts

Allograft
 DFDB allograft
 FDBA’s / Autogenous bone grafts (ABG’s)
 Freeze dried bone allografts
Xenografts
 Bovine anorganic cancellous bone
 Procine non antigenic collagen
Alloplastic materials
 Reabsorb able – β- tricalcium phosphate
 Non absorbable- durapatite, hydroxyapatite
[hard tissue replacement]

 Osteoinductive potential
 Predictability
 Accessability
 Availability – quantity
 Safety
Biologic compactibility
Immunologic acceptability
Minimal sequelae
 Rapid vascularisation
 Minimal operative hazards

BONE FROM INTRAORAL SITES
Osseous Coagulum:
R. Eael Robinson described a technique using
a mixture of bone dust and blood that he termed
“Osseous coagulum”. The technique uses small
particles ground from cortical bone. The advantage
of the particle size is that it provides additional
surface area for the interaction of cellular and
vascular elements.
Source of graft material – Lingual ridge of
the mandible, exostoses, edentulous ridges, bone
removed by osteoplasty or osteotectomy

 Technique: The bone is removed from the
source with a carbide bur # 6 or #8, placed in
a sterile dappen dish and used to fill the
defect.
 Advantages: Ease of obtaining bone from
already exposed surgical site
 Disadvantage: Low predictability and inability
to procure adequate material for large
defects.

Bone blend:
 To overcome the disadvantage of
osseous coagulum, the bone blend
technique has been proposed. It uses
an autoclaved plastic capsule and
pestle. Bone is removed from a
predetermined site, triturated in the
capsule to a workable plastic like mass
and packed into bony defects.
Cancellous bone marrow transplants:
 Cancellous bone can be obtained from the
maxillary tuberosity, edentulous areas and
healing sockets. The maxillary tuberosity is also
contains a good amount of cancellous bone.

Bone swagging:
 This technique requires an edentulous area
adjacent to the defect from which the bone is
pushed into contact with root surface without
fracturing the bone at its base. It is a
different procedure.

BONE FROM EXTRA ORAL SITES:
 Iliac autografts:
The use of fresh or preserved iliac
cancellous marrow bone has been extensively
investigated. However, because of problems
associated with its use, the technique is no
longer in use. Problems like post operative
infection, exfoliation, sequestration etc.

Tissues transferred from one
individual to another genetically dissimilar
individual of the same species.
Undecalcified- freeze dried allograft
FDBA is considered as an osteo
conductive material. It has reported that bone
filling exceeding 50% and in 67% of the defects
grafted with FDBA and in 78% of the defects
grafted with FDBA plus autogenous bone. Have
lesser osteogenic potential than DFDBA. FDBA
mixed with autogenous bone is more effective.

 FDBA, a material readily available from various
bone banks, has been shown to be
osteoconductive. when FDBA is combined with an
ABG, it may become osteoinductive.
 Sepe and colleague in 1978 showed that you can
achieve a 50% or greater bone fill in various types
of defects 60% of the time.
 More recently Saundus and colleagues in 1983
showed that when FDBA is combined with ABG,
there is an 80% chance of achieving 50% of
greater bone fill in all defects.
 Yukna & Sepe used a combination of tetracycline
and FDBA in a 4:1 ratio in 62 defects and where
able to achieve complete fill in 22 sides, greater
than 50% in 39 sites and less than 50% in one
site. These results appears to be better than
those when FDBA is used alone.

 Yukna & Vastardis in 2005 demonstrated
histologically in vitro. FDBA to be significantly
more osteoconductive and osteoinductive than
DFDBA. They concluded that FDBA may stimulate
earlier, more rapid and larger quantities of new
bone formation than DFDBA.
 FDBA, being readily available appears to be an
ideal material for use as a biologic expander when
ABG material is alone insufficient

Decalcified freeze dried bone allograft:
DFDBA is considered as an osteoinductive bone
graft. Have higher osteogenic potential than FDBA. DFDBA in
periodontal defects results in significant probing depth
reduction, attachment Level gain and osseous regeneration.
The combination of DFDBA nad GTR has also proved to be
very successful. DFDBA provides more bone refill than FDBA.
DFDBA grafts results in 2.5 to 3mm of bone fill which is less
than autogenous bone.

 Urist showed the inductive capabilities of DFDB. He
and his colleagues isolated a bone morphogenic
protein (BMP) that is capable of Osteogenic induction
by inducing primordial cells to differentiate into
osteoblasts.
 Demineralization exposes the collagen matrix
that harbors the inductive protein, thereby
permitting greater inductibility, The ideal particle
size is between 250 and 500 µm. This small size
permits high inductive potential, easy resorption and
replacement, increased surface area for primordial
mesenchymal interaction.
 Particles smaller than 250 µmare absorbed quickly
and larger ones are inadequately used.

DFDBA meets all the criteria for ideal grafting
material.
 Availability
 Predictability
 Bio compactability
 Osteo inductivity
 Osteo conductivity
 Cost effectiveness
 Safety

Laurell and colleagues (1998), in meta analysis
review of 21 trials (512 intra bony defects) found
the following.
 DFDBA significantly enhanced bone fill when
combined with DFD without bone grafts.
 The average fill was 1.2 mm for DFD and 2.3 mm
for DFD + DFDBA, irrespective of defect
configuration.
 In comparing the percent of cases
 Defect of 4 -5 mm have a greater percent of
bone fill, bone coverage of deeper defect (greater
than or equal to 6mm). Even though deeper
defects have the potential for the largest amount
of bone fill.

Currently an inorganic bovine
derived bone marketed under the trade name
Bio- Oss has been successfully used both for
periodontal defects and in implant surgery. It is
an osteoconductive porous bone mineral matrix
from bovine cancellous or cortical bone. The
organic components of the bone are removed but
the trabular architecture and porosity is retained.
The physical features permit clot stabilization
and revascularization to allow for migration of
osteoblasts, leading to osteogenesis. Bio- Oss is
biocompatible with the adjacent tissues eliciting
no systemic immune response.

 Available sources: Bovine and Procine
 Different processing technique…. Biocompatible and
structurally similar
 Xenografts are osteoconductive.
 Readily available and almost entirely free of the risk of
disease transmisson.
Two types
 Bovine anorganic cancellous bone (BACB) Bio-Oss
Biolgical apatite crystals –blocks/ granules
 Procine non – antigenic collagen (PNAC) Bio-Oss
collagen
Healthy pigs
Collagen – alkaline treatments- bilayer structure-
eliminate risk of bacterial or viral contamination
Specific purification process… Antigenicity and
Residual fat or protien

BIO-OSS
 Natural, osteo conductive bone subsitute that promotes
bone growth.
 Consists of mineral portion of bovine bone, provides the
body with matrix for the bone cell migration and
integrated into the natural physiologic remodelling
process.
 Its natural bone mineral offers preidictable results which
have been poven through years of clinical experience.
 Bio- Oss : morpholology like human bone.

BIO –OSS COLLAGEN
 It consists of bio oss spongiosa granules(0.25-1 mm) and
10% highly purifieed procaine collagen.
 It is highly porous, posessed a large internal surface area
and functions as a scaffold for bony ingrowth.
 The collagen component enables convenient handling and
simple appplications but doesnot functions as a barrier

PEP - GEN 15
 It is a procaine inoranic bone.
 It contains a synthetic 15 amino acid sequence
with stearic simillarities to the cell binding sites of
type 1 collagen.
 Pep gen P 15 uses a synthetic peptide that is
irreversibly bounbd ot an inorganic bovine derived
material , a natural substance simillar to that found
in human bone.
 It promotes attatchment of reparative cells from
surrounding tissues and facillitates the biometric
environment for bone growth

They are chemically diverse synthetic,
inorganic, biocompatible and bioactive bone
grafts substitutes that are supposed to promote
bone healing through osteoconduction.
Various types:
 Hydroxyapatite
 Ceramics
i) resorbable (β tricalcium phosphate)
ii) non resorbable (bioactive glasses)
 Polymers

Hydroxyapatite:
 Major inorganic component of bone
 Available in porous non resorbable, dense non
resorbable and resorbable forms
 Resorbability of hydroxyapatite is determined
by the temperature at which it is processed.
β tricalcium phosphate (β TCP)
 It is porous form of calcium phosphate
 It serves as a biological filter
 It is partially resorbable, first serving as a
scaffold and then is replaced by bone.
 It is superior to hydroxyapatite in stimulating
bone formation but inferior to bioglass in
stimulating bone formation.

Bioactive glasses
 Bioactive glasses are composed of CaO, NaO, SiO and P2O5.
 When bioactive glasses are exposed to tissue fluids, a layer
of silica gel and calcium phosphate is formed on the surface.
 The soluble silica gel layer promotes bone formation of
osteoblasts through extracellular bone matrix.
Polymers
 They are biocompactible microporous composites of
polymethylmethacetate, polyhydroxyethyl mathaacetate and
Ca(OH)2.
 They are hydrophilic which enhances clotting and their
negative charged particles allow adherence to bone.
 They appear to serve as a scaffold for bone formation when
it close contact with alveolar bone.

The flap is extended atleast one tooth mesial and distal to the
defect for exposure of atleast 2-3mm of surrounding sound
bone. Vertical releasing incisions are optional.
Once the flap are reflected, there are three zones-Root
surface,Soft tissue and Bone are addressed.
ZONE-1:
 The root surface is meticulously scaled and root
planned. Scaling alone is not sufficient because it will not
remove softened or necrotic cementum, bacterial endotoxins,
remnants of junctional epithelium or residual calculus. Enamel
finishing burs are often used to smooth the root surface. If
thorough root preparation is not carried out,the root surface
may not be amenable to cementogenesis are able to sustain
the growth of fibroblast.

ZONE 2: Soft tissue
 With flaps reflected, large curettes are used against
the bony surface to remove all granulation tissue
and residual fibers attached to the bone. All fibers
must be removed to open the marrow spaces and
permit intimate contact between graft material and
bone.

ZONE 3:BONE
 Chronic wounds are often associated with a dense or
sclerotic bone that is poorly vascularized and therefore
less osteogenic than freshly created defects. For this
reasons decortications is performed with round
burs(NO 0.25-0.5)permitting rapid proliferation of
granulation tissue with undifferentiated mesenchymal
cells, rapid degeneration of bone and rapid
anastomoses of graft and bone.
 The graft material is placed in small increments
and care is taken to pack each increment down
adequately while moving excessive fluid.
 Overfilling of graft will compensate for some loss
of graft material but will make primary closure
difficult.

 The flap are reapproximated with digital pressure
to cover the defect completely.
 The vertical mattress or intrapapillary suturing is
ideally recommended using monofilament.
 All grafting technique requires presurgical
scaling, occlusal adjustment as needed and
exposure of the defect with full thickness flap.
The flap technique best suited for grafting
purposes is the papilla preservation flap, because
it provides complete coverage of interdental area
after suturing. The use of antibiotics after the
procedure is generally recommended.

The combination of barrier techniques with bone grafts and
other methods has been suggested and procedures following
these ideas proposed by several authors. The following
technique has been described by Schallhorn and Mc Clain.
 Perform a regenerative type flap. It reuisin has occurred and
coronal flap positioning is required for membrane coverage
periosteal separation is performed.
 Defect is debrided of all granular tissue and the root surface is
planned to remove all reminants of plaque accretions and other
root surface alterations.
 Odontoplasty or osteoplasty are performed if required for
adequate access to the defect including intraradicular or
furcation fundus concavities and reduction of enamel projection.

 The bone graft is prepared in a dapen dish, hydrating it
with sterile saline or local anesthetic solution.
 Appropriate membrane is selected and trimmed to fit the
deserved position and placed on a sterile gauze.
 The area is thoroughly cleansed and isolated and
regenerative site root surface is treated with cotton pellets
soaked in citric acid pH 1-3 minutes taking care that the
solution does not go beyond the root and bone surface.
 If a sclerotic bone surface exists in the graft site,
intramarrow penetration is performed with ¼ .
 The ligament surface is “scrapped” with a periodontal
probe to remove any scar and stimulate bleeding.

 The DFDBA is packed firmly in the defect using an
overfill approach covering the root trunk and
combination or confluent vertical dehiscence or
horizontal osseous defects.
 The custom-fitted membrane is places over the graft
and secured as appropriate.
 The area is rechecked to ensure that adequate graft
material remains in the described area and the flap is
positioned to cover the membrane and recurred with
nonabsorbable sutures.
 The periodontal dressing is passively applied over the
surgical area with surgical covering the sutures..

The future of periodontal regenerative
techniques depends on the emergence of new
products , which will lead to a predictable positive
outcome when used in proper combination in
select sites and patients…

Regenerative osseous surgery

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