1、TARRSON FAMILY ENDOWED CHAIR IN PERIODONTICS,UCLA SCHOOL OF DENTISTRY,Presents,Presents,Dr. E. Barrie Kenney Professor & Chairman Section of Periodontics,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 C
2、linical Specialties UCLA School of Dentistry,Periodontal Regenerative Surgery,O V E R V I E W O F,Regeneration of periodontal defects involves formation of new cementum, new attached periodontal fibers and new bone in a region previously destroyed by periodontal disease.,True regeneration can only b
3、e verified by removing tooth and surrounding bone for histologic evaluation.,True regeneration can only be verified by removing tooth and surrounding bone for histologic evaluation.,Can use most apical margin of calculus as a place to notch the root.,Any cementum with attached periodontal ligament f
4、ibers coronal to this notch is new attachment and if associated with new bone formation, then have most likely periodontal regeneration.,Radiographic evidence of bone fill post surgery is not reliable because of variation in angulation of X-ray beam and variations in processing film between preopera
5、tive and postoperative radiographs.,Following periodontal surgery can have clinically decreased pocket depth, but this may be due to tightly adapted gingiva with a long junctional epithelium. Pocket depth can also be decreased by post surgical gingival recession.,Clinically can evaluate Bone Regener
6、ation by re-entry surgery to measure bone fill, but cannot ascertain if new cementum or new periodontal fibers have formed.,Autogenous Bone is regarded by most clinicians as the “Gold Standard”,Autogenous Bone,AUTOGRAFTS,Collected from burring Mainly cortical bone Contamination (water, oil) Combined
7、 with osseous surgery,Osseous Coagulum,Osseous Coagulum for Bone Induction Robinson RE J. Periodontol. 1969, 40:503,Osseous Coagulum - Bone Blend Verses Flap Curettage,Osseous Grafts III comparison of osseous coagulum bone blend implants with open curettageFroum SJ et al J. Periodontol 1976, 47:287,
8、75 sites in 28 male patients 37 sites in 23 patients, bone graft 38 sites in 13 patients, flap curettage Initial therapy Grooved splints to measure bone fill Re-entries at 7 to 25 weeks,BONE FILL (averages, in mm),Safescraper.3i,Hip Marrow Graft,Cancellous bone Fresh versus frozen Mainly case report
9、s Morbidity of donor site,Autogenous Bone,Minimal standardized data Data shows limited clinical results Based on case reports Similar Gold Standard in sinus lift procedures,No risk of disease or rejection No additional cost of material No commercial sponsor,Decalcified Freeze- Dried Bone (D.F.D.B.),
10、ALLOGRAFTS,Decalcified Freeze- Dried Bone (D.F.D.B.),ALLOGRAFTS,ALLOPLASTS,HYDROXY APATITE FROM CORAL,OR (D.F.D.B.A.),Variable osteogenic capacityViral particles killed in processingLimited success in furcationsAvailable in particles and putty,DFDBA,Particle size = 250 710 microns100% ETOH (reduced
11、lipid content) HCL (Decalcification) Washed & buffered to a pH of 6.8 7 Lyophilized Stoppered under vacuum,6 bone banksImplanted in miceHarvested at 4 and 8 weeks,Ability of commercial demineralized freeze-dried bone allograft to induce new bone formationSchwartz Z, Mellonig JT et al J. Periodontol
12、1996, 9:946,Ability of commercial demineralized freeze-dried bone allograft to induce new bone formationSchwartz Z, Mellonig JT et al J. Periodontol 1996, 9:946,Intramuscular Results at 4 weeks,Ability of Commercial Demineralized Freeze-Dried Bone Allograft to Induce New Bone Formation is Dependent
13、on Donor Age but not GenderSchwartz Z, Somers A, Mellonig JT et al J Periodontol 1998, 69:470,Life net bonePrevious shown activity27 batchesDonor age 16 to 59 years7 female, 20 maleIntramuscular in mice8 weeks,Percentage of New Bone by Donor Subset,Distribution of New Bone Formation,Comparative clin
14、ical study of porous hydroxyapatite and decalcified freeze-dried bone in human periodontal defects.Oreamuno S, Lekovic C, Kenney EB, Carranza FA, Jr., Takei HH, Prokic BJ. Periodontol 1990, 61(7):399-404,Interpore 200 versus Decalcified Freeze-Dried Bone,Comparative clinical study of porous hydroxya
15、patite and decalcified freeze-dried bone in human periodontal defects.Oreamuno S, Lekovic C, Kenney EB, Carranza FA, Jr., Takei HH, Prokic B J. Periodontol 1990, 61:399,Two Groups of paired defects at 2 clinics A & BMean ages 41.4 years, 36.2 years6 month clinical and re-entry data,POCKET DEPTH (in
16、mm),Non-ResorbablePolytetrafluorothylene (PTFE),Membranes for Guided Tissue Regeneration - Non-Resorbable - Resorbable - Periosteum,Resorbable Membranes,Periosteum Polylactide Guidor, Atrisorb Polylactide glycolide Resolut, Osseoquest Collagen Porcine, Biogide Bovine, Biomend Calcium sulfate Plaster
17、 of Paris Capset,Gore-Tex Plus Interpore versus Gore-Tex Alone,Treatment of Class II Furcation Defects using Porous Hydroxyapatite in Conjunction with a Polytetraflourethylene MembraneLekovic V, Kenney EB, Carranza FA, Danilovic V.J. Periodontol. 1990, 71:575,15 patients Mean age 39.4 years Re-entry
18、 at 6 months PHA plus PTFE or PTFE alone,RESULTS AT 6 MONTHS (in mm),Bio-Gide: Composite Porcine Collagen Membrane,Resorbable Membranes (Bio-Gide),Collagen type 1 and 111. Top dense,cell occlusive. Lower porous for cell attachment, clot stabilization.,Bio-Oss Protein extraction of bovine bone to pro
19、duce porous bone mineral hydroxyapatite.,Bio-Oss manufactured by deproteinizing bovine bone with alkali at 300C for 15 hours, then treated with solvent and sterilized.,XENOGRAFTS,Small particle size 0.25 to 1.00 mm also have large particle size 1.00 to 2.00 mm,Ability of deproteinized cancellous bov
20、ine bone to induce new bone formation. Schwartz Z. et al J. Periodontol. 2000, 71:1258,Analyzed 4 batches of Bio-Oss by demineralizing them and found protein average of 11 micrograms per gram. Western blot showed this to be BMP-2 and TGF.,Bio-Oss Plus Bio-Gide versus Flap Debridement,A controlled re
21、-entry study on the effectiveness of bovine bone mineral used in combination with a collagen membrane of porcine origin in the treatment of intrabony defects in humans.J.Clinical Periodontol. 2000, 27:889Camargo PM, Lekovic V, Weinlaender M, Nedic M, Wolinsky LE, Kenney EB.,22 paired defects14 smoke
22、rs 8 non-smokersMean age 43Flap debridement as control6 month clinical and re-entry data,Bio-Oss + Bio-Gide vs Flap Debridement,Bio-Active Molecules Platelet-Rich Plasma (P.R.P.),Platelet Rich Plasma PRPis obtained by sequestering and concentrating platelets by gradient density centrifugation,Platel
23、et Rich Plasma Gel,PDGF Group of polypeptides that stimulate protein synthesis in bone and also stimulate bone resorption, stimulates collagen and matrix production and angiogenesis. TGF beta GROUP of at least 3 polypeptides. Stimulates angiogenesis and production of collagen, ground substance, fibr
24、onectin. Inhibits osteoclasts and stimulates osteoblasts to divide.,PDEGF Stimulates proliferation of keratinocytes and fibroblasts PDAF Stimulates new blood vessel production,IGF-1 Stimulates cartilage growth, bone matrix production and replication of osteogenic stem cells PF-4 Chemoattractant for
25、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.,Platelet enriched plasma Autologous thrombin,Platelet
26、 Rich Plasma,Comparison between Bio-Oss/Bio-Gide/PRP and Bio-Oss/Bio-GidePreparing for publication,23 patients Interproximal defects Mean age 38 9 smokers, 14 non-smokers Re-entry 6 months,Pocket Depth (mm),NO STATISTICALLY SIGNIFICANT DIFFERENCE,Recombinant Human Platelet Derived Graft Factor with
27、DFDBA,Periodontal Regeneration in Human Class II Furcations using Purified Recombinant Human Platelet Derived Growth Factor BB (rhPDGF-BB) with Bone AllograftCamelo 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-m
28、onth results Block sections,Results at 9 months (in mm),Histology shows regeneration coronal to notchBone and cementum fill furcasOne case had cementum formed overenamel projection,Bio-Active Molecules Platelet-Derived Growth Factor (PDGF) GEM21 S PDGF + Beta Tricalcium Phosphate ( T.C.P.),USE OF T.
29、C.P WITH 0.3 mg/ml P.D.G.F. AND TETRACYCLINE ROOT CONDITIONING.,6 months post surgery no re-entry data,Platelet-Derived Growth Factor stimulates bone fill and rate of attachment level gain: results of a large multicenter randomized clinical trial.Nevins M, Han TJ et al. J Perio 2005; 76:2205,Eleven
30、centers with 180 subjects3 groups: (1) T.C.P. + 0.3 mg/ml PDGF(2) T.C.P. + 1.0 mg/ml PDGF(3) T.C.P. + bufferIncluded smokers up to 1 pack per day; all got tetracycline root treatment at surgery, a few got re-entry. No pocket data available.,Clinical Attachment Level Gains,Bone Fill at 6 Months (from
31、 Radiographs),6-Month Pocket Depth Changes (from package insert),Bio-Active Molecules Bone Morphogenetic Proteins (B.M.P.),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 bovin
32、e 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 osteoblast
33、s induce formation of osteoprogenitor cells and stimulate new bone formation.,Bone Morphogenetic Proteins,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. T
34、his 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.,Recombinant BMPs require up to 10 times more than native BMPs to give the same osteogenic activity.,BMPs are assayed by intramuscular injection
35、 into rodents and so initiate osteogenesis.,BMPs need carrier to get effective bone initiation.Ideal carrier still not found.,Carriers:Demineralized Bone MatrixCollagenResorbable polymersCalcium phosphate materials,Recombined human Bone Morphogenetic Protein-7 in maxillary sinus floor elevation surg
36、ery in 3 patients compared to autogenous bone grafts.Van den Bergh JPA. et alJ. 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,Highest
37、concentrations of BMP gave best clinical results,25 patients with grade II furcations in lower molars. Five with BMPGroup 1 0.00 control DFDBA alone.Group 2 3.13 micrograms per mg of DFDBAGroup 3 6.25 micrograms per mg of DFDBAGroup 4 12.50 micrograms per mg of DFDBGroup 5 25.0 micrograms per mg of
38、DFDBAEvaluated at 6 months no re-entry,6 Month Clinical results using DFDBA plus Bovine Derived Protein,Bio-Active Molecules Enamel Matrix Derivatives: Amelogenin Emdogain,Enamel matrix derivative protein in propylene glycol alginate solution. Used in root conditioning with orthophosphoric acid or E
39、DTA.,Emdogain contains amelogenin, a matrix protein produced by ameloblasts and reduced enamel epithelium of root sheaths.,Combination use of bovine porous bone, mineral enamel matrix proteins and an absorbable membrane in intrabony periodontal defects in humansLekovic V., Camargo P.M., Weinlaender
40、M., Kenney E.B., Vasilic N. J. Periodontol 2001, 72:583,18 paired defects 10 male, 8 female 12 smokers, 6 non-smokers Mean age: 42 years 6 months clinical and re-entry data Control: flap debridement,Bio-Oss plus Emdogain and Bio-Gide composite (collagen, polylactic acid),Pocket Depth (mm),Attachment
41、 Level (mm),Osseous Resective Surgery,A Longitudinal Study of Comparing Scaling Procedures, Osseous Surgery and Modified Widman Procedures: Results After 5 Years Becker W, Becker BE, Caffesse R, Kerry G, Ochsenbein C, Morrison E, Prichard J. J. Periodontol. 2001, 72:1675,Private practice environment
42、 Experts in each technique No selection of best defects for each technique,Dr. W. Becker calibrated and did all measurements. All patient got two 1-hour units of scaling and root planing by hygienist. Baseline data 3 to 4 weeks post scaling.,Random assigned quadrants for root planing by Dr. W. Becke
43、r. Osseous surgery by Dr. C. Ochsenbein, Dr. W. Becker and Dr. B.E. Becker. Modified Widman by Dr. G. Kerry.,Patients seen weekly for 6 weeks post-surgery for polish and oral hygiene instruction. Placed on 3-month recalls. Data collected yearly 4 to 6 weeks after last recall.,9 of 16 patients compli
44、ant with recalls,Plaque Index,Pocket 7mm or Greater,Attachment Levels 7mm or Greater,Gingival Recession in mm (Pocket 7mm or Greater),Periostat Plus Root Planing,Subantimicrobial Dose of Doxcycline Enhances the Efficacy of Scaling and Root Planing in Chronic Periodontitis: A Multicenter TrialPreshaw
45、 PM et al J. Periodontol 2004, 75:1068,210 Patients with 5 to 9 mm pockets and BOP Up to 1 hour per quadrant scaling and root planing with L.A. 9-month results Used 20mg Doxycycline b.i.d. or placebo Current smokers 25.5% placebo, 38.8% Periostat,Pockets 4 to 6 mm,Pockets 7mm or more,POCKET DEPTH (in mm),Bio-Oss + Bio-Gide vs Flap Debridement,THE END,
