1. TARRSON FAMILY ENDOWED CHAIR IN PERIODONTICS

2. UCLA SCHOOL OF DENTISTRY

3. Presents Dr. E. Barrie Kenney Professor & Chairman Section of Periodontics

4. E. Barrie Kenney B.D.Sc., D.D.S., M.S., F.R.A.C.D.S. Tarrson Family Endowed Chair in Periodontics. Professor and Chairman Division of Associated Clinical Specialties UCLA School of Dentistry

5. Platelet Rich Plasma –PRP is obtained by sequestering and concentrating platelets by gradient density centrifugation Platelet Rich Plasma Gel

6. Platelet rich plasma gel is an autologous modification of fibrin glue made by mixing platelets and fibrinogen centrifuged from whole blood with thrombin and calcium chloride. Increase platelet concentration in wound by more than 300 percent. The PRP is then mixed with calcium chloride and bovine thrombin to form clot that binds bone graft material. Bovine thrombin has been used in cardiovascular surgery and there are 32 reported cases of bleeding disorders due to cross reactivity of bovine factor V causing antibodies to human factor V. No cases seen in bone grafting use of PRP. Can substitute human recombinant thrombin or patient’s own thrombin separated out in a separate protocol or extra purified bovine thrombin.

7. Harvest System 3i System Average Platelets in 6 ml 1.5 million1.2 million Time for Isolation 15 minutes20 minutes Preparation of Platelet Rich Plasma (P.R.P.) Use of general purpose centrifuges 1.450 ml blood in citrate – phosphate anticoagulant placed in centrifuge at 5,600 rpm to get buffy coat of platelets plus leukocytes 2.Slow centrifugation of buffy coat at 2,400 rpm to obtain 30 ml of platelet rich plasma. Takes 30 minutes and should be used within 6 hours

8. PDGF – Group of polypeptides that stimulate protein synthesis in bone and also stimulate bone resorption, stimulates collagen and matrix production and angiogenesis. TGF betaβ GROUP of at least 3 polypeptides. Stimulates angiogenesis and production of collagen, ground substance, fibronectin. Inhibits osteoclasts and stimulates osteoblasts to divide. PDEGF Stimulates proliferation of keratinocytes and fibroblasts PDAF Stimulates new blood vessel production

9. IGF-1 Stimulates cartilage growth, bone matrix production and replication of osteogenic stem cells PF-4 Chemoattractant for fibroblasts and PMNS PRP mainly used in sinus lifts with autogenous bone, DFDBA or bovine bone. Case reports suggest increased rate of bone formation. However, in studies by FROUM et al using PRP – Bio-Oss no difference seen in bone in sinus lifts.

10. Platelet enriched plasma Autologous thrombin

11. Platelet Rich Plasma plus Bio-Oss plus Biogide versus Platelet Rich Plasma and Bio-Oss Comparison of Platelet Rich Plasma, Bovine Porous Bone Mineral and Guided Tissue Regeneration versus Platelet Rich Plasma and Bovine Porous Bone Mineral in the treatment of Intrabony defects: a Re-entry Study Lekovic V, Camargo PM, Weinlaender M, Vasilic N, Kenney EB J. Periodontol 2002, 73:198 21 Paired Defects 6 Males, 15 Females 9 smokers 12 non-smokers Mean age 40 years 6 month clinical and re-entry data

12. Initial6 Months PRP+BioOss + Biogide 7.813.62 PRP+BioOss7.963.98 PRP+BioOss + Biogide PRP+BioOss Attachment Gain (mm) 4.123.78 Bone Fill (mm) 4.964.82 Pocket Depth (in mm)

17. Platelet Rich Plasma plus Bio-Oss plus Atrisorb versus Atrisorb alone Platelet Rich Plasma and Bovine Porous Mineral combined with guided tissue regeneration in the treatment of intrabony defects in humans. Camargo PM, Lekovic V, Weinlaender M, Vasilic N, Madzarevic M, Kenney EB J Periodont. Res 2002, 37:300 18 paired defects 10 males 8 females 6 smokers 12 non-smokers Mean age 39 years 6 month clinical and re-entry data Atrisorb-Polylactide in n methyl 2 pyrrolidine.

18. Initial6 Months PRP+BioOss + Atrisorb 7.872.89 Atrisorb7.784.16 PRP+BioOss + Atrisorb Artisorb Attachment Gain (mm) 4.372.62 Bone Fill (mm) 4.782.31 Pocket Depth (mm)

19. Bio-Oss plus Bio-Gide plus Platelet Rich Plasma versus Flap Debridement A Re-entry study on use of Bovine Porous bone mineral guided tissue regeneration and Platelet Rich Plasma in the treatment of intrabony defects in humans. Camargo PM, Lekovic V, Weinlaender M, Vasilic N, Madzarevic M, Kenney EB Int. J. Periodont. Rest. Dent. 2005, 25:49 28 Paired Defects 12 Females 16 Males Mean age 41.0 years 12 Smokers 16 Non-smokers Clinical and re-entry data at 6 months

20. Initial6 Months Bio-Oss+ Bio-Gide+PRP 7.872.89 Flap Curettage7.784.16 Bio-Oss+ Bio-Gide+PRP Flap Curettage Attachment Gain (mm) 4.372.62 Bone Fill (mm) 4.782.31 Pocket Depth

26. Platelet Rich Plasma Comparison between Bio-Oss/Bio-Gide/PRP and Bio-Oss/Bio-Gide Preparing for publication 23 patients Interproximal defects Mean age 38 9 smokers, 14 non-smokers Re-entry 6 months

27. Initial6 Months Bio-Oss+ Bio-Gide+PRP 8.193.31 Bio-Oss + Bio-Gide 8.113.95 BioOss+ Biogide+PRP BioOss + Biogide Attachment Gain (mm) 4.383.56 Bone Fill (mm) 4.813.96 Pocket Depth (mm) NO STATISTICALLY SIGNIFICANT DIFFERENCE

28. ControlPDGF Fibroblasts9.3 ± 2.070.8 ± 14.6* Cementoblasts0.4 ± 0.22.5 ± 0.5* Osteoblasts0.5 ± 0.23.6 ± 0.7* Perivascular Cells2.7 ± 0.67.2 ± 1.3 Endothelial Cells0.7 ± 0.23.7 ± 1.0 HIGHLY PURIFIED RECOMBINANT PLATELET DERIVED GROWTH FACTOR

29. Recombinant Human Platelet Derived Graft Factor with DFDBA Periodontal Regeneration in Human Class II Furcations using Purified Recombinant Human Platelet Derived Growth Factor – BB (rhPDGF-BB) with Bone Allograft Camelo M et al Int J Periodont Rest Dent 2003, 23:213 3 mandibular molars, 1 maxillary 2 got 0.5mg/ml PDGF+DFDBA 2 got 1.0mg/ml PDGF+DFDBA 9-month results Block sections

30. VerticalprobingHorizontalprobingAttachment CasesBeforeAfterBeforeAftergain 0.5mg/ml82746 83734 1.0mg/ml62534 53641 Results at 9 months (in mm) Histology shows regeneration coronal to notch Bone and cementum fill furcas One case had cementum formed over enamel projection

31. .

32. THE END

34. TRI CALCIUM PHOSPHATE PORES 1-500 MICRONS PARTICLES 0.25 -1.00 MM.

35. USE OF T.C.P WITH 0.3 mg/ml P.D.G.F. AND TETRACYCLINE ROOT CONDITIONING.

40. 6 months post surgery few re-entries done

46. 1 week post surgery

47. 6 months post surgery

50. THE END

52. Genetically engineered human Bone Morphogenetic Proteins increase the amount and purity. Osteogenin is another name for B.M. P. Most osteogenins are bound to a carrier of bovine type I collagen sponge or other carrier. First isolated in acid extracts of human bone by URIST in 1965. Are part of superfamily of 43 transforming growth factor beta group. At least 16 different proteins isolated. BMP1 not part of superfamily is a procollagen protease. BMPs secreted by osteoblasts induce formation of osteoprogenitor cells and stimulate new bone formation. Bone Morphogenetic Proteins

53. BMPs 2, 4, 5, 6, 7 needed for regulation of osseous tissue and for repair. Some are more osteoconductive, e.g., BMP2 and BMP7 more active than BMP5. URIST at UCLA first identified BMP in 1965. This native BMP is present in minute amounts (1mg per kg of bone), so need large amounts of bone to produce. Therefore, recombinant BMPs have been developed.

54. Recombinant BMPs require up to 10 times more than native BMPs to give the same osteogenic activity. BMPs are assayed by intramuscular injection into rodents and so initiate osteogenesis.

55. BMPs need carrier to get effective bone initiation. Ideal carrier still not found. Carriers: Demineralized Bone Matrix Collagen Resorbable polymers Calcium phosphate materials

56. Used human BMP (osteogenin) Collaplug and DFDBA, in humans. Took 36 block sections from 8 subjects with submerged roots and 50 non-submerged defects in 6 patients. Used calculus as a baseline measurement of regeneration. Histologic comparison of Regeneration in Human Intrabony defects when Osteogenin is combined with Demineralized Freeze-Dried Bone Allograft with purified bovine collagen. Bowers G. et al J Periodontol. 1991, 62:690

57. 36 Submerged Defects New Bone New Cementum New Attachment Collaplug0.080.110.08 Collaplug + BMP 0.200.080.05 DFDBA 2.481.731.72 DFDBA + BMP 2.702.352.33 50 Non-Submerged Defects New Bone New Cementum New Attachment Collaplug0.781.260.74 Collaplug + BMP 0.701.200.67 DFDBA 1.321.751.31 DFDBA + BMP 1.982.311.92 No significant difference between DFDBA and DFDBA+BMP *DFDBA+BMP significantly better than all other groups Bowers

58. Recombined human Bone Morphogenetic Protein-7 in maxillary sinus floor elevation surgery in 3 patients compared to autogenous bone grafts. Van den Bergh JPA. et al J. Clinical Periodontol. 2000, 27:627 --1 sinus with BMP-7 had good bone --1 sinus no bone but cyst like mass --2 sinuses had small amount of bone insufficient for implants --All 5 autogenous sinus grafts had good bone

59. A feasibility study evaluating rhBMP-2 absorbable collagen sponge for maxillary sinus floor augmentation. Boyne P. et al Int. J. Perio. Res. Dent. 1997, 17:11 6 patients 3 got BMP-7 in collagen in 4 sinus lifts 3 got autogenous iliac bone in 5 sinus lifts At 6 months took out bone cores.

60. Got good bone in cores One patient had mucus retention cyst on CT at 16 weeks Got mean bone height increase of 8.51 mm to 15.73 mm –8 to 11 patients had sufficient bone for implant placement. –2 biopsies at 19 weeks had moderate amount of bone –10 biopsies at 24 to 27 weeks had moderate to large amounts of bone. Collagen sponge bovine type 1 collagen 12 patients with sinus lifts evaluated with CT scans at 16 weeks and bone biopsies (7 cases) at 14 weeks to 27 weeks.

61. This Bovine protein extract (Neo osteo, Sulzer) contained Bone Morphogenetic Proteins 2, 3, 4, 6, 7, 12, 13. Bovine derived bone protein extract in the treatment of mandibular class II furcations. Camargo PM, Wolinsky LE, Burgess AJ, Wagner WR, Paluk SF, Kenney EB. Compend. Cont. Edu. Dent. 2002, 23:1023

62. 25 patients with grade II furcations in lower molars. Five with BMP Group 1 0.00 control DFDBA alone. Group 23.13 micrograms per mg of DFDBA Group 36.25 micrograms per mg of DFDBA Group 412.50 micrograms per mg of DFDB Group 525.0 micrograms per mg of DFDBA Evaluated at 6 months no re-entry Control Group 1 Group 2 Group 3 Group 4 Group 5 Pocket Depth Change 1.31.01.11.81.7 Vertical Attachment Level Change 0.50.80.51.5 Horizontal Attachment Level Change 1.90.50.41.11.8 6 Month Clinical results using DFDBA plus Bovine Derived Protein

63. Highest concentrations of BMP gave best clinical results

69. THE END