Understand the indication and contra-indication for periodontal surgery and when to

do regeneration. Particularly biological width

In clinical practice, our aim is to restore to health for the remaining periodontium
Ideal goal of periodontal therapy is the regeneration of the periodontium to predisease levels but…

 When crestal bone is lost, its generally impossible to restore it.

 INFRABONY defect can sometimes heal with regeneration

Surgical therapy should be seen as a adjunct to cause related therapy

 To facilitate remove of subgingival deposits and plaque control

When we are trying to “remove bone loss”, Downgrowth of epithelial cells for gingiva
much quicker than growth of PDL cells, preventing regrowth of the periodontium.
That’s why we tend to get repair more than regeneration.
Formation of pockets
 Presence of bacterial plaque on tooth surface  marginal gingiva become
inflamed  Gingiva sulcus deepens due to oedematous enlargement of gingiva
 enlarged pocket Anaerobic organism tend to colonise the subgingival
plaque (Spirochaetes and motile rods)  Large number of PMN leukocytes and
macrophagesmigrates to the gingiva tissue in response to bacterial challenge 
leads to collagen loss by:
 1: Lysosomal enzymes (collagenase) released by PMN leukocytes and
destruction of collagen fibre in gingival.
 2: Fibroblast phagocytose collagen fibres by extending cytoplasmic process to
the ligament cementum interface
After 1+2, collagen fibres apicak to junctional epitheliao gets destroyed, the
epithelial cells proliferate along the root surface in an apical direction and contact
with healthy collagen fibres.
Therefore… junctional epithelium gets detached from the tooth surface
This lead to pocket formation

How do we regenerate??
 Bone Replacement Grafts
 Root Surface Conditioning
 Surgical Technique
 Guided Tissue Regeneration
 Enamel Matrix Proteins
Indication for regeneration
 Infrabony defects (Infrabony defects when bone resorption occurs unevenly, an
oblique direction, Infrabony defects can have one, two or three walls) where
 performing open flap debridment (is a periodontal procedure in which the
supporting alveolar bone and root surfaces of teeth are exposed by incising the
gingiva to provide increased access for scaling and root planing.) would result in
uneven contour of bone and residual pockets
 3 wall defect- 95% defects filled completely with bone
 2 wall defect- 82% defects completely filled with bone
 1 wall defect 39% defects completely filled with bone
 Cortellini 1993b (5 mins)
 Of course, good OH is important to maintain the gingiva condition.
 Furcation involved teeth

Guided tissue regeneration (GTR)

 Basically, different type of cells contact with the roots would have different
issues
 1. If we have epithelial cells, you get to form Long junctional
epithelium.
 2. If we have gingival connective tissue, we might end up root
resorption
 3. If we have alveolar bone indirect contact with the root, this
cause root resorption and ankyloses
 4. If we have periodontal ligament, this would develop CT
attachment (This is good)
 From this diagram, if we have membrane (barrier) to block the
epithelium from contacting the root, then we can get
connective tissue, new bone and new PDL
 Types of barrier
 Non-resorbable (called ePFTE, Goretex)
 Basically need the pt to come back and
remove it next time, we usually don’t use this
anymore
 Resorbable (Polylactic acid, polyglygolic acid)
 Factors affecting the outcome:
 Surgeon - technique sensitive
 Patient - systemic disease, smoking, stress, plaque control, compliance
 Defect - depth & width (basically we wont shallow and narrow), no. bony
walls (2-3), access (need to debride the area), tooth topography
 Surgical factors - infection control, wound stability, space maintenance,
quantity and quality of gingiva
  Post-Op factors - infection and plaque removal, membrane retrieval, tooth
stability
 Guided Tissue Regeneration –
 Clinical Outcomes In deep infra-bony pockets and compared to
conventional flap surgery, more gain in clinical attachment (+1-2mm) and
less residual probing depth (-1mm)
 Really only mandibular II furcations respond better and predictably better
than conventional surgery
 Smoking and poor OH likely to result in recurrent disease

Enamel Matrix Proteins (

 Enamel Matrix Proteins are deposited on the root surfaces during
embryogenesis and promote subsequent formation of cementum, PDL and
alveolar bone
 Porcine enamel matrix proteins available as a gel (Emdogain), which is applied
to surgically exposed and citric acid-etched root surfaces
 This stimulates the growth, (one of the growth factor), which gets new
cementum forming (should be acellular cementum appear in the coronal 2/3 of
the root)
 Steps
 So… 2 wall and 3 wall would have better
result
 We need to open the access and debride
the area, apply EDTA (a weak acid) for 2
mins then apply the emdogain (Enamel
Matrix Proteins).
 (refer to lecture slides for clinical pictures)
Bone Replacement Grafts
 Materials
 Autogenous bone (From yourself, from intra-oral/extraoral side)
 Allogenic bone (From others)
 Biodegradable synthetic graft materials (Perioglas)
 Non-absorbable synthetic materials (Plaster of Paris)
 Xenografts (Bio-Oss) (from a donor of a different species)
 Bio-oss have similar structure to human bone, its meant to allow new
cells and blood supply to come in there. It is slowly replaced overtime
but there will be some % (~30 after 10 years) still remain and its not
going to cause any reaction
 Basically, the “materials” needs to be inert and biocompatible.
 For bone regeneration, there are 3 definitions
 Osteoconduction
 Acts as a matrix or scaffold (just act as space filler)
 Osteoinduction (the ability of graft material to induce stem cells to
differentiate into mature bone cells)
 Message in gragft (some growth factors in it)
 Osteogenic (materials contain viable cells with the ability to form bone
(osteoprogenitor cells))
 Contains cells to produce new bone,
 Only autologous which is from yourself
 For bone growth want:
 stable base of bone
 blood supply growing from this base
 release of appropriate growth factors
 Bone cells migrating from walls of defect will repopulate as far as
blood supply allows
 Indications for Bone Grafting
 Deep intraosseus defects (angular defect)
 Regeneration
 Aesthetic?
 Aggressive Periodontitis
 Furcations? (gotta be class 2 mandibular furcations)
 Just rmb, you cannot build up the crest of bone, we are just adding
stuff into the empty space
 This is more indicated for implants, wouldn’t use this for perio surgery
  Growth Factors & Bone Grafting
 Growth factors essential for new bone formation
 Platelets release a number of factors including PDGF, TGF-b and IGF
 Can use these factors to increase amount of bone formed especially if
used in combination
 Platelet-rich plasma
 Bone Morphogenic Proteins

Surgical technique
 Wanna make sure we remain the gingiva tissue at the flap area.
 Reverse-bevel incision allows readaption of flap to root surface that is virtually
devoid of epithelium on its inner surface
 Use technique that leaves root-surface coagulum interface protected
 Coronally advance flap to protect clot