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PERIODNTAL REGENERATIVE THERAPY & Bio -materials

PERIODNTAL REGENERATIVE THERAPY & Bio -materials. EFFECTIVE IN PERIODONTAL SURGERY OR NOT ?????. PERIODONTITIS ? ? ?. Deep intra-osseous defect. Periodontitis. Inflammatory disease Of the Supporting Tissues Of Teeth resulting in PROGRESSIVE DESTRUCTION of the Periodontal Ligament

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PERIODNTAL REGENERATIVE THERAPY & Bio -materials

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  1. PERIODNTAL REGENERATIVE THERAPY & Bio-materials EFFECTIVE IN PERIODONTAL SURGERY OR NOT ?????

  2. PERIODONTITIS ? ? ? Deep intra-osseous defect

  3. Periodontitis • Inflammatory disease • Of the Supporting Tissues Of Teeth • resulting in PROGRESSIVE DESTRUCTION of the Periodontal Ligament • And Alveolar Bone • with either Pocket Formation/Recession • or both.

  4. Pathogenesis-Multifactorial.

  5. DIAGNOSIS- PROBING

  6. TREATMENT • Arrest The Inflammatory Disease Process • By Removal Of The Subgingival Biofilm • Establish A Local Environment And Microflora • Compatible With Periodontal Health.

  7. Perio Treatment Non-Surgical Therapy Surgical Therapy

  8. We Are Here To Discuss The Surgical Option For Periodontitis Today

  9. Remove Biofilm Regenerate the Lost Tissue Maintain Results GOALS OF SURGICAL RX

  10. Wound Healing- Outcomes • Scarring • Repair – long junctional epithelium • Regeneration – New PDL, Cementum, bone

  11. Optimal Outcome Of Treatment- Regenerate The PeriodontiumTo Its Pre-disease State Proven by Histological Evidence of Regeneration –both architecture and function…

  12. To be considered a regenerativemodality, a material or technique mustHISTOLOGICALLY DEMONSTRATE that bone, cementumand a functional periodontal ligament (A New Attachment Apparatus) can be formed on a previously diseasedroot surface.

  13. Regeneration Repair • Bio-materials: • New Cementum • New Periodontal Ligament • New Bone Scaling/Root Planing Flap surgery

  14. World Workshop in Periodontics of theAmerican Academy of Periodontology (1996) Requirements For A Periodontal Treatment To Be Considered A Regenerative Procedure : • Animal Histological Studies revealing new cementum, periodontal ligament and bone. • Human Clinical Trials demonstrating improved clinical probing attachment and bone levels; and • Human Histological Studies - demonstrating new cementum, periodontal ligament and bone coronal to the former defect base

  15. End-point Of Treatment • The goal of clinical research is to provide UNEQUIVOCAL EVIDENCE regarding the potential tangible benefits of a treatment. • Periodontal research cannot afford to keep stopping short of this goal

  16. Bio-Materials Vs. Perio Regeneration

  17. Periodontal Regeneration… • GUIDED TISSUE REGENERATION - periodontal regeneration using barrier membranes - in order to avoid the apical migration of epithelium • INDUCED TISSUE REGENERATION - using specific substances able to induce the regenerative process - growth/differentiation factors or enamel matrix derivatives

  18. Guided Periodontal Regeneration • Generation 1 – GTR • Generation 2- Bio-materials like EMD, BMP, PRP…. • Generation 3- Growth Factors, Stem Cells, Tissue Engineering..

  19. Guided Periodontal Regeneration- Many Options available…to confuse us.

  20. Guided Tissue Regeneration Generation 1 – of periodontal Regeneration…. Nyman, Karring et al… Nyman S, Lindhe J, Karring T, Rylander H. New attachment following surgical treatment of human periodontal disease. J Clin Periodontol 1982: 9: 290–296.

  21. GTR - Rationale • To use a physical barrier - barrier membrane • To selectively guide cell proliferation • And tissue expansion • Within tissue compartments

  22. GTR –Barrier Membrane • Prevents gingival epithelium and connective tissue expansion • And favors migration of Cells From The Periodontal Ligament • And alveolar bone into the periodontal defect.

  23. GTR- Concepts Gingival Epithelium Periodontal Ligament Connective Tissue Alveolar Bone Melcher AH. On the repair potential of periodontal tissues. J Periodontol 1976: 47: 256–260.

  24. Types of Membranes- • Non-Resorbable • Resorbable - Biodegradable

  25. Disadvantages -Non-Resorbable • 2nd Surgery Required • Exposure to Oral environment • Bacterial contamination • Failure of collapse in non-cross-linked

  26. Disadvantages -Resorbable • Risk Of Exposure • Collapse Into The Defect Area- Bone Filler Is Needed • Technique Is Sensitive And Technically Demanding. • Harmful Degradation Products Of Synthetic Membranes

  27. GTR- Tough, Technique-Sensitive Procedure…

  28. GTR- Disadvantages Other postoperative complications • swelling, • erythema, • suppuration, • sloughing or perforation • of the flap, • membrane exfoliation • and postoperative pain have been reported in independent studies

  29. GTR -Cochrane Systematic Review -16 RCT’s • Increase in attachment gain for GTR over open flap debridement - 0.02 to 3.60 mm/mean difference 1.22 mm, 95%CI [0.8,1.64]) • This value is not a valid estimate of effect because the heterogeneity is substantial and statistically significant. • A substantial variation in their results –not consistent. IAN NEEDLEMAN, RICHARD TUCKER, Periodontology 2000, Vol. 37, 2005, 106–123

  30. GTR -Cochrane Systematic Review -16 RCT’s- by IAN NEEDLEMAN, RICHARD TUCKER, Periodontology 2000, Vol. 37, 2005, 106–123 Until CONSISTENT BENEFITS from GTR can be shown open flap debridement should remain the control comparison.

  31. Or do GTR and Pray it works out well…

  32. Generation 2 Biomaterial for - Periodontal Regeneration….

  33. What are Bio-Materials? Biologic Mediators - used for Periodontal And Maxillofacial Regeneration

  34. What are Bio-Materials? Partially Purified Protein Mixture From Developing Teeth. Or – Morphogens (Growth Factors) – From Recombinant Technology.

  35. Biomaterials- EMD/BMP/PRP/PRF…..

  36. Ideal Requirements of Bio-materials • Biocompatability, • Enhancement Of Clinical Attachment Levels, • Reduction Of Probing Depths • And Hard Tissue Fill Of The Intrabony Defects.

  37. Bio-materials - for PeriodontalRegeneration Enamel Matrix Derivatives Bone morphogenetic Proteins Platelet Rich Plasma/Fibrin..

  38. EMD- Enamel Matrix Derivative

  39. EMD- Enamel Matrix Derivative (Emdogain) The major (>95%) component of EMD is AMELOGENINS Extracellular Matrix Proteins - purified acid extract of proteins from pig enamel matrix

  40. Enamel Matrix Derivatives… • Releases Bioactive Peptides • Stimulation - Local Growth Factor Secretion And Cytokine Expression • Induces - Regenerative Process- Amelogenin Deposition Precedes Cementum Formation- Recruitment Of Cementoblasts To The Denuded Root-surfaces.

  41. EMD-EMDOGAIN GEL (Straumann)

  42. Enamel Matrix Derivatives…Systematic Review,2002- Trombelli et al. • Meta Analysis of Froum et al. 2001, Okuda et al 2000, Pontoriero et al. 1999, Silvestri et al. 2000, Tonetti et al. 2002 • Results showed no evidence of an effect of the predictor on difference in CAL gain between EMD/OFD (P 0.81). • Change in PPD- 1.60mm (95% CI: 0.59–2.62) Trombelli L, Heitz-Mayfield L, Needleman I, Moles D, Scabbia A: A systematic review of graft materials and biological agents for periodontal intraosseous defects. J Clin Periodontol 2002;

  43. EMD-Cochrane Database of Systematic Reviews, 2009-Esposito M et al. • Thirteen trials  - EMD significantly improved PAL levels (1.1 mm) and PPD reduction (0.9 mm) • High degree of heterogeneity ( ???) • Sensitivity analysis indicated that the overall treatment effect might be overestimated • The actual clinical advantages of using EMD are unknown.

  44. Evidence-Based Dentistry (2003) 4, Vibeke Baelum and Rodrigo Lopez • EMD is able to significantly improve PAL levels (1.3 mm) and PPD reduction (1 mm) compared with flap surgery . • The authors use absence of statistical significance to conclude that they were unable to explain the heterogeneity found between the studies. • The CAL improvements attributable to EMD therapy may not have a great clinical impact. 

  45. Clinical Consideration’s Short - Half-life /Biological degradation of material is a concern - ??? Whether commercial batches of enamel matrix derivative will be consistent and provide comparable clinical results in all cases???

  46. EMD- Only Cellular Cementum Instead of the development of AEFC, a partially mineralized connective tissue formed that contained many embedded cells, but no extrinsic fibres. This tissue may thus be classified as bone-like or as a cementum-like tissue- But not Acellular Extrinsic Fiber cementum Effects of enamel matrix proteins on tissue formation along the roots of human teeth Dieter D. Bosshardt, Anton Sculean, Niklaus P. Lang J Periodont Res 2005; 40; 158–167. Blackwell Munksgaard 2005

  47. Evidence-Based Dentistry (2003) 4, Vibeke Baelum and Rodrigo Lopez Where patients have intrabony defects, is surgery with enamel matrix derivative more effective than other treatments?

  48. Evidence-Based Dentistry (2003) 4, Vibeke Baelum and Rodrigo Lopez Currently, the evidence for a possible benefit of EMD in the treatment of intrabony defects IS RATHER WEAK.

  49. No.2 Biomaterial- BMP

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