牙周再生性手术 Regenerative Periodontal Surgery

1. 24 牙周再生性手术 Regenerative Periodontal Surgery 手术的目的在于获得牙周组织再生的手术，叫做再生性手术 the use of regenerative procedures aimed at restoring the lost periodontal support

2. Periodontal Regeneration? 牙槽骨 ＰＤＬ 牙骨质 牙周组织再生

3. 牙周膜血管通道 牙周前体细胞 牙周膜 牙周组织再生的细胞生物学基础

4. 24-1 引导组织再生术 Guided Tissue Regeneration Following flap surgery, the curetted root surface may be repopulated by (1) epithelial cells, (2) Gingival connective tissue cells, (3) bone cells, or (4) periodontal ligament cells.

5. 原理 The exclusion of epithelial and gingival connective tissue cells from the healing area by the use of a physical barrier may allow (guide) periodontal ligament cells to repopulate the detached root surface. This observation provided the basis for the clinical application of the treatment principle termed "guided tissue regeneration" (GTR).

6. Drawing illustrating the placement of the physical barrier which prevents the epithelium and gingival connective tissue from contacting the root surface during healing. At the same time the membrane allows cells from the periodontal ligament (arrow) to repopulate the previously periodontitis-involved root surface.

7. Microphotograph of membrane (M) covered root.

10. 用于再生性手术的屏障膜材料 Barrier Materials for Regenerative Surgery Essential design criteria: Biocompatibility: good tissue acceptance Barrier: exclude undesirable cell types from entering the secluded space adjacent to the root surface. Tissue integration : tissue may grow into the material without penetrating all the way through. Maintaining a space maintaining a space adjacent to the root surface. Easy to trim and to place.

11. Maintaining a space

12. Barrier materials for regenerative surgery Non-Bioabsorbable materials PTFE

13. Bioabsorbable materials

14. 手术要点： 1，膜的放置位置 2，瓣缝合 3，术后护理 4，膜的放置时间

15. Cases

19. 24-2 植骨术　Bone Graft Procedures

20. 植骨用材料 Graft Materials The grafting materials in periodontal bony defects may be: 成骨 osteoproliferative (osteogenetic), which means that new bone is formed by bone forming cells contained in the grafted material 骨引导osteoconductive, which means that the grafted material does not contribute to new bone formation but serves as scaffold for bone formation originating from adjacent host bone 骨诱导osteoinductive, which means that bone formation is induced in the surrounding soft tissue immediately adjacent to the grafted material.

21. The various graft and implant materials used so far can be placed into four categories: 自体骨Autogenousgrafts: Grafts transferred from one position to another within the same individual. This type of graft comprises (1) cortical bone or (2) cancellous bone and marrow, and is harvested either from intraoral or extraoral donor sites. 异体骨Altogeneic grafts: Grafts transferred between genetically dissimilar members of the same species. (1) Frozen cancellous bone and marrow, and (2) freeze-dried bone have been used. 异种骨Xenogencic grafts: Grafts taken from a donor of another species. 骨替代品Alloplasticmaterials: Synthetic or inorganic implant materials which are used as substitutes for bone grafts.

22. BIO-OSS（牛骨）

23. Alloplastic materials Bioactive glasses (Bio-glasses) Beta-tricalcium phosphate (3-TCP) Polymers Hydroxyapatite (HA)

24. 牙周植骨的适应症 骨下袋 II度根分叉 手术要点: 尽量保留龈组织, 尽量少用内斜切口 尽量用保留龈乳头切口 充分暴露术区, 彻底清创 骨移植物不可超出缺损 严密缝合覆盖

25. 24-3 促进细胞附着和牙周组织再生的其他方法 Other Techniques to Promote Periodontal Regeneration 牙周组织工程学 Periodontal tissue Engineering 根面处理 Root Treatment 多肽生长因子的 Polypeptide Growth 富血小板血浆 Pallet Riched Plasma PRP 联合应用 Combined Applications

26. 病变根面生物学性能的改变 Root surface biomodification Root surface treatment biomodification of the root surface with enamel matrix proteins (EMD) Removal of bacterial deposits, calculus and endotoxins Demineralization of the root surface, exposing the collagen of the dentin (Citric acid , tetracyclineEDTA) inducing mesenchymal cells in the adjacent tissue to differentiate into cementoblasts. the formation of a new connective attachment facilitate adhesion of the blood clot to the root surface to be able to promote periodontal regeneration.

27. Root surface conditioning/biomodification by means of an etching procedure may serve several purposes: 不同制剂根面脱钙可能的作用 • removal of the smear layer following mechanical debridement • demineralization of the root surface (citric acid) • selective removal of hydroxyapatite and exposure of the collagenous matrix of the root surface (EDTA) • local delivery of antimicrobial compound (tetracycline HCL) • inhibition of collagenolytic activity (tetracycline HCL) • enhancing cellular responses (migration and attachment) • preventing epithelial down-growth • improving retention of different biomolecules to exposed collagen • expressing a cementoblast phenotype for colonizing cells.

28. EMD的生物学功能

30. ＰＲＰ技术－富血小板血浆 • 血小板便贴附于血凝块并开始脱颗粒，释放出至少三种生长因子：Platelet-derived growth factor( PDGF)、Transforming growth factor beta1(TGF-β1) 和Transforming growth factor beta2(TGF-β2) • 　　分离和浓缩后的PRP，其血小板浓度可达　59万-400万个/ml,而全血中的血小板浓度平均值为11万-52万个/ml, 血小板浓度增加了近338%

32. 术前 术后６个月

33. 体外牙周组织工程 生物性牙种植 牙胚构建－植入 牙周牙体初级复合(hybrid)构建－植入 + + 天然牙根牙周组织构建植入

34. 24-4　牙周再生治疗的评价　Evaluation of Periodontal Regeneration Periodontal probing X-ray Re-entry