1. Year Three Periodontology #7 Elio Reyes, D. D. S. ,M. S. D
Year Three Periodontology #7 Elio Reyes, D.D.S.,M.S.D. Reconstructive Periodontal Surgery Furcation Management Chapter 67

2. Repair or Regeneration?
Repair Healing of a wound tissue that does not fully restore the architecture or function of the part.
May see new gingival connective tissues and possibly new bone
Critical factor is how these tissues connect to the root surface.
In repair there is no development of new cementum and no development of a new PDL. It is only a partial restoration of the supporting periodontal tissues
The newly regenerated gingival connective tissues and possible new bone attach to the root via a long junctional epithelium or connective tissue adaptation.

3. Periodontal wound healing
Epithelium
Gingival connective tissue
Alveolar bone
Periodontal ligament
Karring T, Nyman S, Lindhe J:J Clin Periodontol 1980; 7:394
Karring T, Nyman S, Lindhe J:J Clin Periodontol 1984; 11:41

4. Repair or Regeneration?
Regeneration is defined as a reproduction or reconstitution of a lost or injured part.
Regenerated tissues attach to the root surface in a similar manner to the original attachment. Thus, after healing is complete, connective tissue attaches to the root via a new PDL which engages fibers emerging from the root surface which is covered by new cementum. When needed, new bone also forms in the appropriate location.
Need to remove the junctional and sulcular epithelium for regeneration.

5. A B
Repair and Regeneration. The arrow indicates the most apical part of the junctional epithelium. A, Repair, healing by long junctional epithelium. Note that some bone is new but the PDL is not. B. Regeneration, new alveolar bone, new PDL, new cementum.

6. long junctional epithelium
regeneration

7. Consider regenerative procedure with an intrabony defect with good
blood supply.

8. Points to remember This is not new attachment
The probing depth is reduced by resolution of the inflammation and subsequently the probe does not penetrate as deeply.
This is not new attachment
New connective tissue fibers will not attach to the root surface if epithelium is present.
PDL provides the cells needed for regeneration.
Less probe
penetration with
resolution of the
Inflammation.
Probe penetrates past
the junctional epithelium
because of inflamed tissue

9. Epithelium Control Delay epithelial migration
Coronal displacement of the flap
Epithelial exclusion
Guided tissue regeneration
Cells from the pdl have the potential for regeneration

10. Figure 42-3 Sources of regenerating cells in the healing stages of a periodontal pocket. Left, Intrabony pocket. Right, After therapy the clot formed is invaded by cells from A, the marginal epithelium; B, the gingival connective tissue; C, the bone marrow; and D, the periodontal ligament.

11. Epithelium Control Clot stabilization
Undisturbed and stable maturation of the clot usually prevents apical migration of the epithelium
Coronally positioned flaps place the wound margin away from the critical healing site
Space maintenance
Important in guided tissue regeneration
Keep membrane from collapsing into the defect
Use titanium reinforced membranes

12. Tissue Healing Responses
Epithelium
Connective Tissue
Bone
Periodontal Ligament

14. Guided Tissue Regeneration
GTR consists of placing barriers of different types to cover the bone and periodontal ligament, thus temporarily separating them from the gingival epithelium.
Excluding the epithelium and the gingival connective tissue from the root surface during the post surgical healing phase not only prevents epithelial migration into the wound but also favors repopulation of the area by cells from the periodontal ligament and the bone.

15. Membranes classification
Resorbable
Non-resorbable

16. Membranes classification
Non-resorbable membranes
First membranes used
Require a second surgical procedure
Most extensive evaluated membranes
Gold standard

17. Membranes classification
Non-resorbable membranes
Nucleopore and Millipore filters
Ultrathin semipermeable silicon barriers
Rubber dam
ePTFE
dPTFE (non porous)
Melcher,AH: J Periodontol 1976;47: 256
Aukhil I: J Periodontol 1986; 57:727
Salama H: Int J Periodont Restor Dent 1994;14:16

18. Guided Tissue Regeneration (GTR)
Non-resorable membranes
Needs additional surgical procedure to remove membrane
Example: Gore-Tex® polytetrafluoroethylene (e-PTFE)

19. Figure 67-9 Different shapes and sizes of expanded polytetrafluoroethylene membranes marketed by Gore-Tex (Flagstaff, Ariz).

20. Membrane –blocks epithelium and the gingival connective tissue;
allows nutrients to pass;
titanium reinforced if needed.
Healing from bone and PDL

22. ePTFE Gore-Tex. Transgingival microstructure
Partially occlusive portion
Open microstructure portion
For applications involving
a structure, such as a tooth,
that extends trough the gingiva
into the oral environment
Product Information 2003: WL Gore & Associates, Inc.

23. ePTFE Titanium reinforced
Titanium struts incorporated between two sheets of ePTFE
Same characteristics of ePTFE
Added shapeability and space making
Product Information 2003: WL Gore & Associates, Inc.

24. Guided Tissue Regeneration (GTR)
Resorbable membranes
Bioabsorbable or biodegradable
Polylactid acid, Polyglycolic acid
Examples:
Vycril® Polyglactin 910
Resolut®, Resolut XT® PGA-PLA
Good handling characteristics, remains intact for 8 to 10 or 16 to 24 weeks then gradually resorbs.
Collagen membranes. Perdominantly type I collagen
Biomend, Biomend extent, Ace.
Excellent handling, biodegrades in 16 or more weeks.

25. Collagen membranes Various collagen subtypes: Predominantly type I
Initially used as gel or matrix to fill or cover periodontal defects
Various collagen subtypes: Predominantly type I
Derived from different animal sources: bovine, porcine; tendon, dermis
Laurell L, Gottlow J: Int Dent J 1998;48
Wang HL:Dent Clin North Am 1998; 42:3

26. Resolut XT 3-layer structure Occlusive copolimer of PLA and PGA 85:15
Porous structure with trimethylene carbonate
Porous structure of glycolide and trimethylene carbonate copolimer fiber
Occlusive membrane of synthetic bioabsobable glycolide and lactide polimer
Resolut XT 8-10 weeks
Cross section: 2 random fiber
matrices on gingival and defect
sides of a cell occlusive film
Surface with Trimetric pattern
Increases membrane flexibility
Product Information 2003: WL Gore & Associates, Inc.
Laurell L, Gottlow J: Int Dent J 1998;48

27. McClain and Schallhorn Int. J. PERIO REST DENT 1993
5 Year results evaluating 76 sites in 32 patients
Guided Tissue Regeneration was significantly enhanced by the addition of root conditioning and grafting procedures
Used citric acid for root conditioning and DFDBA
Sites treated showed good long term stability

28. Success of GTR Machtei et al J. Perio 1994
Mandibular class two furcations
30 subjects with a one year surgical re-entry
Probing depth reduction of 2.6 mm
Horizontal probing attachment gain of 2.62 mm
Vertical gain of 0.95 mm
Pre-surgery SRp was not helpful
Better results in those subjects with greater initial pocket depth, good oral hygiene, minimal inflammation and sites that did not harbor AA

29. Root Preparation Mechanical Hand instruments Sonics and Ultrasonics
Finishing burs
Chemical
Citric acid
Fibronectin
Tetracycline hydrochloride
EDTA 24%, ph neutral (PrefGel®)

30. For very tenacious calculus or in those cases where the calculus and cementum are indistinguishable, consider using a high-speed rotary diamond or a diamond – studded ultrasonic scaler. Must have direct vision via flap procedure.

31. smoothest root surface followed by manual and power-driven scalers.
During surgical root preparation, fine diamonds or finishing burs produce the
smoothest root surface followed by manual and power-driven scalers.

33. Preparation of the Root Surface
Citric acid
pH 1 for 2-3 minutes
Produces a 4 μm (micron) deep demineralized zone with exposed collagen fibers
Eliminates endotoxins and bacteria from the tooth surface
Retards epithelium from migrating over treated roots
Removes smear layer and widens orifices of dentinal tubules

34. Preparation of the Root Surface -2-
Fibronectin
A glycoprotein to help fibroblasts attach to root surfaces
Tetracycline Hydrochloride
Paste made from a tetracycline capsule.
In addition to the effects noted for citric acid also see an anti-collagenolytic or collagen stabilizing effect plus a lingering antibacterial effect
EDTA 24% ph neutral PrefGel®
Ethylene diamine tetra acetic acid

35. Manual Instrumentation
Ultrasonics
Finishing Burs
Chemical

36. Tissue engineering aims to enhance bone grafts with growth factors
PDGF Platelet derived growth factor
IGF Insulin like growth factor
TGF Transforming growth factor alpha and beta
Tissue engineering aims to enhance bone grafts with growth factors

37. Growth Factors Dr. Sam Lynch SIU/SDM
PDGF Platelet derived growth factor
Recombinant (rhPDGF) is supplied with an inert filler (beta-tricalcium phosphate) which is mixed before insertion

38. Periodontal Regeneration Adjunctive Agents
EMDOGAIN® Tissue Engineering.
An enamel matrix protein (mainly amelogenin) derived from developing tooth buds of fetal pigs (porcine).
Accelerate the growth of the pluripotential stem cells from the PDL. The primitive cells from the PDL win the race to close the wound with new cementum, PDL and bone rather than epithelium.
Packaged in a syringe as a viscous gel that is applied to the root surface.
Need to completely control bleeding before applying this product
J.Perio 2000: Emdogain® produces a positive effect on the osteoblast

39. Platelet Rich Plasma (PRP)
Developed from patient’s blood with a cell separator
Centrifugation of 55 ml of whole blood results in approximately 10 ml of PRP which when mixed with thrombin and calcium chloride results in the degranulation of platelets and the subsequent release of growth factors
Growth factors include PDGF TGFβ etc
PRP stimulates both hard and soft tissue maturation and promotes healing

40. The ideal bone graft material should
Be biocompatible
Completely biodegradable
Osteoconductive, osteoinductive, osteogenic
Inexpensive
Easy to handle
Able to support the defect area until bone growth is complete

41. Types of grafting materials
Origin:
Autogenous: Autograft
Human Tissue: Allograft
Animal: Xenograft
Synthetic: Alloplast

42. Bone Grafts Autografts
Intraoral sites
Osseous coagulum
Obtained by using rotary instruments on intraoral bone at the surgical site
Bone blend
Cortical or cancellous intraoral bone that is obtained with a trephine, chisel or rongeur. It is placed in an amalgam capsule and triturated into particle size in the range of 100 to 200 microns.
Cancellous Bone Marrow. Maxillary tuberosity, healing sockets (8 to 12 weeks) edentulous areas.
Bone swaging

43. Bone Swaging

44. Bone Grafts Autografts
Extraoral sites
Iliac bone
Root resorption
Not practical to use

45. Allografts Graft between genetically dissimilar members of the same species
Freeze-Dried Bone
Particle size 250 to 750 μm
Mineralized or Demineralized
Hydrochloric acid demineralization exposes the bone inductive proteins, collectively called bone morphogenic proteins (BMP).
For periodontal defects DFDBA is utilized because it is osteoinductive.
For ridge augmentation or extraction site fill, the bone is not decalcified (FDBA) resulting in a product that better retains its form (osteoconductive).

46. Bone Grafts Terminology
Osteoconduction. A physical effect by which the matrix of the graft forms a scaffold that favors outside cells to penetrate the graft and form new bone.
Osteoinduction. A chemical process by which molecules contained in the graft (bone morphogenic protein) convert the neighboring cells into osteoblasts, which in turn form bone.

47. Allografts (continued)
Freeze-Dried Bone…
Ability to induce bone formation may vary with processing
Age of donor may play a factor
BMP varies from bone to bone bank.
Osteogenin or bone morphogenic protein 3 (BMP3) appears to enhance osseous regeneration and is added to some bone grafting products.
AlloGro®. Donor tissue material bioassayed for osteoinductive activity.
Inactive DFDBA can be made more effective by adding recombinant human bone morphogenic protein
See better results when DFDBA is combined with autogenous bone
Probability that DFDBA might contain HIV following appropriate screening and processing procedures has been calculated at 1 in 8 million.

48. Xenografts Graft obtained from a member of one species and transplanted to a member of another species.
Most common xenograft used today is organic bovine bone.
PepGen P-15®
Combination of a cell-binding peptide (p-15) with anorganic bovine-derived hydroxyapatite bone matrix.
P-15 is a synthetic clone of the 15 amino acid sequence of Type 1 collagen that is uniquely involved in the binding of cells, particularly fibroblasts and osteoblasts.
PepGen P-15 Particulate
PepGen P-15 Putty
PepGen P Flow (syringe)

49. Alloplasts Synthetic grafting materials
Not a reliable substitute for autografts or allografts.
Usually heals by fibrous encapsulation.
Convenient, no significant osteoinductive capacity. Examples:
Calcium Sulfate. Plaster of Paris
Capset®
Plastic Materials
HTR® (hard tissue replacement)
Calcium coated polymer of Poly-methyl methacrylate and hydroxy ethyl methacrylate
Calcium Phosphate: Hidroxyapatite, βTCP
Bioactive Glass: Perioglass

50. Calcium sulfate as a bone graft
Oldest bone graft material. Not expensive, easily stored and used.
Properties of calcium sulfate
An effective barrier membrane
Maintains space for osteogenesis
Has angiogenic properties
Has a hemostatic function
Can deliver growth factors
Can be used in combination with other bone graft materials
Often mixed with DFDBA
Is osteoconductive
Commercial brand is CAPSET® -- medical grade calcium sulfate
Time release calcium sulfate undergoes controlled and uniform degradation over a period of 16 weeks. BoneGen®

51. Alloplasts -2- Calcium Phosphate Hydroxyapatite (HA) Ceramic nonporous
Examples: Calcitite® Osteogen®
Generally nonbioresorbable
Tricalcium phosphate (TCP) Ceramic nonporous
Examples: Synthograft® and Peri-OSS®, Carrier of Gem21®
Partially bioresorbable
Porous HA
Example: Interpore®

52. Alloplasts -3- Bioactive Ceramic Glass Example: (PerioGlass®)
Silicon dioxide 45%; sodium oxide 24.5%; calcium oxide 24.5%; phosphorus pentoxde
When in contact with tissues attracts osteoblasts
Non resorable?

53. Bone Grafts
Evidence indicates that significant bone fill beyond that of debridement controls can be expected following the use of bone grafts.
Mean defect fill averages approximately 60 to 65% in a number of studies.
Histologic evidence indicates some regeneration occurs after the use of autogenous grafts, DFDBA, and Xenografts.
No confirmed regeneration using non-bone products

54. Bone Grafts New bone formation starts at 7 days
Cementogenesis at 21 days
New periodontal ligament at 3 months
Radiographic evidence of increasing bone density often not seen until 6 months
Maturation of grafted material may take up to 2 years

55. Treatment of Infrabony Defects after Edward S. Cohen -1
1. Full thickness mucoperiosteal flap using sulcular incisions.
Conservation of interproximal tissue to achieve primary closure.
Flap extended at least one tooth mesial and distal to the defect.

56. Treatment of Infrabony Defects after Edward S. Cohen -2
2. Removal of plaque, calculus, softened cementum, and the junctional epithelium from the root surface.
Ultrasonics, hand instruments, finishing burs, smooth diamond stones are utilized.

57. Treatment of Infrabony Defects after Edward S. Cohen -3
3. Removal of all granulation tissue and residual fibers attached to the bone.
Fibers must be removed to open the marrow spaces and permit intimate contact between graft material and bone.
Use large curettes against the bony surface.
Missed any infrabony defects? Look for bleeding.

59. Treatment of Infrabony Defects after Edward S. Cohen -4
4. Chemical root treatment?
Citric acid, tetracycline, PrefGel®.
5. Decortification
Small holes made in bone using curette or small round bur.
Permits a rapid proliferation of granulation tissue with undifferentiated mesenchymal cells thus see a more rapid regeneration of bone and anastomosis of graft and bone.

61. Treatment of Infrabony Defects after Edward S. Cohen -5
6. Scrape the PDL with the tip of an explorer to promote bleeding and stimulate cell proliferation.
7. Placement of the graft material and/or barrier membrane.
8. Flaps are sutured for primary closure and coronal positioning.
9. Postoperatively
Antibiotics in most cases. Analgesics. Chlorhexidine. Ice. Recall q. 2 weeks, then monthly.

64. Six Years Later

65. Furcation Involvement and Treatment.

66. Treatment of Furcation Involvement
Vertical / Horizontal component
Concerns
Root trunk
Concavities
Degree of root separation
Enamel projections
Caries
Occlusion

67. Figure 68-1 Glickman's classification of furcation involvement
Figure 68-1 Glickman's classification of furcation involvement. A, Grade I furcation involvement. Although a space is visible at the entrance to the furcation, no horizontal component of the furcation is evident on probing. B, Grade II furcation in a dried skull. Note both the horizontal and the vertical component of this cul-de-sac. C, Grade III furcations on maxillary molars. Probing confirms that the buccal furcation connects with the distal furcation of both these molars, yet the furcation is filled with soft tissue. D, Grade IV furcation. The soft tissues have receded sufficiently to allow direct vision into the furcation of this maxillary molar.

68. Different anatomic features that may be important in prognosis and treatment of furcation involvement. A, Widely separated roots. B, Roots are separated but close. C, Fused roots separated only in their apical portion. D, Presence of enamel projection that may be conducive to early furcation involvement.

69. >3mm horizontal is a class two Hamp furcation involvement
It is the horizontal component that distinguishes furcation involvement.
>3mm horizontal is a class two Hamp furcation involvement

70. Treatment options with furcation invasion
Grade one furcation invasion
Resolve the pocket
Odontoplasty if narrow and inaccessible
Remove enamel projection if present
Grade two furcation invasion
Regenerative procedures especially in mandibular molars
Grade three furcation invasion
Open furcation for patient access (mandibular)
Root removal
Extraction
Maintain in a compromised state

71. Treatment options with furcation invasion
Grade one furcation invasion
Resolve the pocket
Odontoplasty in some cases
Grade two furcation invasion
Regenerative procedures especially in mandibular molars
Tooth with a class two furcation has a guarded prognosis not a poor prognosis
Grade three furcation invasion
Open furcation for patient access (mandibular)
Root removal
Extraction
Maintain in a compromised state

72. Treatment options with furcation invasion
Grade one furcation invasion
Resolve the pocket
Odontoplasty in some cases
Grade two furcation invasion
Regenerative procedures especially in mandibular molars
Grade three furcation invasion
Open furcation for patient access (mandibular)
Sometimes called a tunnel procedure
Root removal
Extraction Implant?
Maintain in a compromised state