6 Osseous Surgery.gtr

7/23/2019 6 Osseous Surgery.gtr

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Dr S Olusegun Nwhator (BDS, FMCDS, FWACS)

Senior Lecturer/Consultant Periodontologist

Lead Researcher, Periodontal Medicine Research Group


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Treatment of Osseous Defects

1. Osseous Resection

2. Debridement

3. Grafting


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Infrabony Defect

Base of pocket is apical to the alveolar crest

One osseous wall

Two osseous walls

Three osseous walls


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Ostectomy vs osteoplasty

Ostectomy resecting --sacrifice some supportive bone

Osteoplasty-- Reshaping without sacrificing supporting bone


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Indications for Osseous Resection

Wide 3-wall defects

Interproximal craters

Hemiseptums

Furcations

Thick alveolar bone


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Indications for bone grafts

Periodontal defects

Alveolar ridge augmentation

Extraction site bone fill

Sinus augmentation


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Types of bone grafts

Autografts Maxillary tuberosity

Mandibular ramus Chin

Extraction socket

Tori

Edentulous ridges


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Osseous Coagulum

Exotoses, edentulous ridge

Bone Dust & Blood

Crbide bur (5,000-30,000 rpms)

Pack coagulum into defect

Small particles more active in inducing

regeneration of periodontium


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Allografts

Bone from another human (Cadaver)

lIiac cancellous bone

Freeze-dried (50% fill)

Decalcified freeze-dried

(Cortical better than cancellous)


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Bone Morphogenic Proteins (1-9)

Protein with osteogenic potential

Advantages of Allograft Bone

No donor site morbidity

Preservation of patients tissue

Reduced surgical time

Availability

Utility


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Demineralized Freeze Dried Bone

From cadavers

Advantages

Quantity

Predictability

No adverse reactions


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Non Bone Graft Materials

Glass granules

Plastic Materials (HTR Polymers)

Tricalcium phosphate

Plaster of Paris (CaSO4)

Hydroxyapatite

Cartilage

Sclera

Calcium Phosphate

Others


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Can allografts transfer disease?

Considered safe


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Guided Tissue Regeneration

FACULTY OF DENTAL SURGERYWEST AFRICAN COLLEGE OF SURGEONSUPDATE COURSE IN CLINICAL DENTISTRY

05/02/2015


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The Junctional Epithelium

Forms the base of the sulcus

Joins gingiva to tooth surfaceRanges from 0.71 to 1.35 mm

15 to 30 cells thick at coronal zone

4 to 5 cells thick at apical zone

Non-keratinized

Wide intercellular spaces and desmosomes

Dense granules

Permeability barrier,

Phagocytotic activity

Derived from the reduced enamel epithelium


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The Disease Process


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The Disease Features

Bleeding on probing

Epithelial migration of the JE

Pocket formation

Suppuration

Pocket ulceration

Pockt deepens and anerobic environ

perpetuates inflammation


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Intervention-Periodontal therapy


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Intervention-Periodontal therapy


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Ultimate Goal

To achieve healing and the restoration of

periodontal health.


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Scaling and root planing goals

To remove calculus

To provide a smooth surface

To remove endotoxin

Reduced bleeding

Gingival shrinkage (by 2 wks),

Connective tissue reattachment (by 4wks)

Probing pocket depth reduction

Reduced tooth mobility


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Do we achieve this goal???


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Defining terms

Repair - Epithelial adaptation

New Attachment formation

Regeneration


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Is this the ultimate goal???

Restablishes a normal gingival sulcus

Arrest bone destruction

No gain in clinical attachment

No gain in bone height

Repair


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Reattachment

Repair of areas not previously exposed to the pocket

After cemental fractures or treatment of

periapical lesions

Attachment of flap to areas of the tooth from whichit has been removed in the course of

treatment



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Epithelial Adaptation

Close apposition without gain in height ofgingival attachment-Long junctional

epithelium to the tooth surface,

Epithelium Attachment



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New attachment

Attachment of new PDL fibers into

new cementum on a tooth surface with

adequate bone support in areas previously

lost to disease.


If yes, how do we achieve it?


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Achieving the goal

New periodontal ligament fibers

New cementum

Adequate bone support

In areas previously lost to disease.

New attachment


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Obstacles!!

Fast-moving epithelial tissue in JE

JE migrates into the defect space

Cementum excluded

Periodontal ligament excluded

Result=long junctional epithelium


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Why the obstacles! Different origins of periodontal tissues

Difference growth rates of periodontal tissues

Epithelial growth ahead of mesenchymal

At best, epithelial growth only achieves

Epithelium AttachmentLong junctional epithelium

Close apposition without gingival attachment




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Addressing the obstacles

Difference growth rates of periodontal tissues

Rational for intervention:

== create an environment to allow for

differences in growth rate.


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Epithelial growth ahead of mesenchymal

Rational for intervention

== Exclude the epithelium to differentially allow

for growth and attachment of the mesenchymaltissues to the treated root surface.


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Epithelium Attachment


== aim to obtain a new attachment of actual

periodontal tissues like the PDL, cementum andalveolar bone.


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Long junctional epithelium

== Prevent the formation of long junctional

epithelium by keeping the junctional epithelium

away long enough to allow for new attachmentof PDL and cementum to the root surface.


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Close apposition without gingival attachment


== Achieve close adaption with new periodontal

tissues to achieve new attachment.


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Ultimately Create an environment to allow for differences in growth rate.

Exclude the epithelium to differentially allow for growth and

attachment of the mesenchymal tissues to the treated rootsurface.

Obtain a new attachment of actual periodontal tissues like thePDL, cementum and alveolar bone.

Prevent the formation of long junctional epithelium bykeeping the junctional epithelium away long enough to allow

for new attachment of PDL and cementum to the rootsurface.

Achieve close adaption with new periodontal tissues toachieve new attachment.


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Create an environment allowing for different growth rates

Exclude the fast-growing epithelium

Prevent the formation of long junctional epithelium

Achieve close adaption with new periodontal tissues Obtain a new attachment of actual periodontal tissues


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Guiding the way the periodontal tissues

regenerate in a way that produces predicable

results.



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Guided Tissue Regeneration


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History of Guided Tissue Regeneration

Early 1980s

Stre Nyman and Thorkild Karring---influence of 4 tissuetypes on periodontal healing

Gingival connective tissue,

Gingival epithelium

Periodontal ligament

BoneJan Lindhes leadership


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Pioneer Human Experiment

Selectively isolating the gingiva from a healing

periodontal defect could result in regeneration

of the periodontal ligament and cementum.


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Barriers timeline

Simple nonporous cellulose acetate filters Gold foil

Gore- tex--extremely inert and biocompatible

Expanded polytetrafluoroethylene (ePTFE)

Silicone button with pokerchip ePTFE


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pokerchip epTFE---unique node and fibrilstructure for rapid cell integration.

over 90% air and internodal spaces of more

than 100 m


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Basic principles

Isolation encourages healing of the desired tissue.

A cell isolating biomaterial must meet minimum standards

Structural and biocompatibility requirements are important

Should encourage organized and vascularized ingrowth

Should limit epithelial invagination,

Should promote regenerative rather than scar-type healing

Success depends on flap design and membrane coverage

Membranes should protect the healing tissues


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Initial blood clot is important

Grafting materials help maintain volume in regeneration site

Thorough site preparation/ cleaning, flap preparation

Good primary closure should be aimed at

Adequate vascularity for secondary healing is important

Management of potential infection affects success


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Ideal properties of GTR barriers

1. Tissue Integration --allow for organized vascular and

connective tissue ingrowth

2. Encourage regenerative healing and inhibit epithelium

3. Selective cell Separating

4. Provide necessary nutrient, blood supply

5. Clinically Manageable

6. Space-maintaining - for stable clot formation

7. BiocompatibleFrom 1982-1992:ADecadeofTechnologyDevelopment

ofGuidedTissueRegeneration Scantlebury 1993


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ePTFE membranes


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Initial attempts


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Definition

GTR is a procedure through which the

exclusion of epithelial and gingival connective

tissue cells from the healing area by the use of

a physical barrier may allow or guideperiodontal ligament cells to repopulate the

detached root surface. --Chander Kumar


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Definition

GTR is a form of periodontal therapy that affords

unimpeded development and movement of

progenitor cells toward the root surface which had

previously undergone attachment loss due to

periodontal disease.

GTR is the facilitated movement of the progenitor

cells toward the treated root surface with exclusion

of gingival epithelial cells and fibroblasts.


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Basis

Wound closure is mostly achieved by the

apical migration of gingival epithelial cells.

These cells subsequently adhere to the root

surface resulting in wound closure through along junctional epithelial attachment .

The LGE does not resemble the original

attachment apparatus of periodontal ligament

fibers.


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Basis

1. The periodontium contains progenitor cells for cementum, pdl a

alveolar bone. Melcher ,1976

2. The progenitor cells reside in the periodontal ligament

3. Gingival connective tissue and gingival epithelium excluded

4. Prevented from contacting the root surface during healing

5. Exclusion achieved with a barrier membrane

6. Regeneration --re constitution /complete restoration

7. Complete restoration of lost or injured perio tissues

8. Reformation of cementum, periodontal ligament & alveolar bon


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The GTR Theory

With traditional therapy, restoration of periodontal

tissues previously lost to chronic periodontitis is often

minimal and unpredictable.

Placing a barrier between the overlying gingival tissues

and the bony defect excludes fast-moving epithelium and

gingival cells from contacting the root surface

This gives time for Cementum, periodontal ligament and

bone to repopulate the defect.


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The GTR Theory

Progenitor PDL cells differentiate into cementocytes

and periodontal ligament fibroblasts.

These two cells produce a new attachment apparatus

which results in a wound closure which resembles

the attachment apparatus prior to chronic

periodontitis.


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Indications for Guided Tissue Regeneration

Two or three wall vertical defects

Interproximal defects

Distal defects

Class II and class III furcation Defects

Gingival recession


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Contraindication of Guided Tissue Regeneration

Inadequate zone of gingival tissue

A defect morphology that does not allow for space

creation and maintenance Uncontrolled diabetes

Anti coagulant therapy

Acute infection/inflammation

Allergy to bovine products


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Products for Guided Tissue Regeneration

First Generation:

Millipore filter

Expanded PTFE(Gore-tex)

Nucleopore membrane


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Second Generation (resorbable):

Collagen membrane

Polylactic acid membrane (guidor)

Vicryl mesh

Cargile membrane

Oxidase cellulose

Hydrolysable polyester


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Third Generation:

Resorbable materials + growth factors


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Procedure for Guided Tissue Generation

1. Make an incision using a size 15 surgical blade

2. Preserve the attached keratinized interdental papillae

3. Vertical relieving incisions may help create wider access

4. Vertical incisions 1tooth mesial and/or distal to the site

5. Raise full thickness flap and perform adequate debridment

6. Rotary, sonic and ultrasonic devices for SRP are desirable

7. Measure the defect with a periodontal probe

8. Select an appropriately sized template and try on defect

9. Hydrate approximately 5 to 10 minutes


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10. Membrane should extend 3mm beyond all defect margins

11. Trim template and place against the collagen membrane

12. Check that membrane is coronal to alveolar crest

13. Check that membrane is apical to the gingival margin

14. Secure membrane in place with a resorbable suture

15. Check that membrane fits snugly against the root

16. Check that membrane is draped over the alveolar bone


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How about osseous grafts

Osseous grafts in conjunction with GTR

enhances bone regeneration.

A bone graft could be obtained from the same

patient --autogenous graft or from freeze-dried human bone graft material --allograft


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8 mm pocket


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Incision


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Root defect exposed


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Bio-oss in place


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Membrane in place


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Sutures in place


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Dressing in place


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A

B

C

D

D

E


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Armamentarium


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Post-operative instructions

Chlorexidine mouthrinse- b.d 4-6 wks

Avoid brushing site for two weeks

Gentle brushing - 3 weeks

Resume gentle brushing with a soft toothbrush

Review in 24 hrs, then weekly for 4 weeks

Increase review time as appropriate

Antibiotic coverage - 14 days


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Things to note

Membrane should be completely absorbed eight weeks

Evaluate plaque, bleeding and tooth mobility indices

Allow 6 months before probing


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Smooth and rough sides

Smooth side is compact and cell occlusive Guaranteesprotection against connective tissue.

This side faces the soft tissue.

The rough side consists of collagen fibers

It is loose & porous It enables cell invasion

It enhances the integration of bone forming cells

It stabilizes the blood clot

This side faces the bone defect

Neonem either side

Smooth & rough sides


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Smooth & rough sides


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Things to look out for!!

Swelling of surgical site

Thermal sensitivity

Excessive gingival bleeding

Dehiscence of flap

Gingival recession.

Root resorption or ankylosis


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Different materials

Capset --Calcium sulfate

Resolut-Polyglycolic acid + poly (lactic acid-co-glycolic acid)

Emdogain-Enamel matrix protein+ Amelogenins Porcine

with Surface-cementum forming cells

Biomend--collagen

Guidor--Polylactic acid + citric acid ester

Atrisorb D Free Flow-- 4 % Doxycycline


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Success determinants


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Nyman S, Lindhe J, Karring T, Rylander h. New attachment followingsurgical treatment of human periodontal disease. J Clin periodontol

1982;9:290-6.

Melcher Ah, Dreyer CJ. protection of the blood clot in healing

circumscribed bone defects. J Bone Joint Surg Br 1962;44-B:424-30.

Dahlin C, Linde A, Gottlow J, Nyman S. healing of bone defects by

guided tissue regeneration. plast Reconstr Surg 1988;81(5):672-6.

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6 Osseous Surgery.gtr