7/23/2019 6 Osseous Surgery.gtr
1/89
Dr S Olusegun Nwhator (BDS, FMCDS, FWACS)
Senior Lecturer/Consultant Periodontologist
Lead Researcher, Periodontal Medicine Research Group
7/23/2019 6 Osseous Surgery.gtr
2/89
Treatment of Osseous Defects
1. Osseous Resection
2. Debridement
3. Grafting
7/23/2019 6 Osseous Surgery.gtr
3/89
Infrabony Defect
Base of pocket is apical to the alveolar crest
One osseous wall
Two osseous walls
Three osseous walls
7/23/2019 6 Osseous Surgery.gtr
4/89
Ostectomy vs osteoplasty
Ostectomy resecting --sacrifice some supportive bone
Osteoplasty-- Reshaping without sacrificing supporting bone
7/23/2019 6 Osseous Surgery.gtr
5/89
Indications for Osseous Resection
Wide 3-wall defects
Interproximal craters
Hemiseptums
Furcations
Thick alveolar bone
7/23/2019 6 Osseous Surgery.gtr
6/89
Indications for bone grafts
Periodontal defects
Alveolar ridge augmentation
Extraction site bone fill
Sinus augmentation
7/23/2019 6 Osseous Surgery.gtr
7/89
Types of bone grafts
Autografts Maxillary tuberosity
Mandibular ramus Chin
Extraction socket
Tori
Edentulous ridges
7/23/2019 6 Osseous Surgery.gtr
8/89
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
7/23/2019 6 Osseous Surgery.gtr
9/89
Allografts
Bone from another human (Cadaver)
lIiac cancellous bone
Freeze-dried (50% fill)
Decalcified freeze-dried
(Cortical better than cancellous)
7/23/2019 6 Osseous Surgery.gtr
10/89
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
7/23/2019 6 Osseous Surgery.gtr
11/89
Demineralized Freeze Dried Bone
From cadavers
Advantages
Quantity
Predictability
No adverse reactions
7/23/2019 6 Osseous Surgery.gtr
12/89
Non Bone Graft Materials
Glass granules
Plastic Materials (HTR Polymers)
Tricalcium phosphate
Plaster of Paris (CaSO4)
Hydroxyapatite
Cartilage
Sclera
Calcium Phosphate
Others
7/23/2019 6 Osseous Surgery.gtr
13/89
Can allografts transfer disease?
Considered safe
7/23/2019 6 Osseous Surgery.gtr
14/89
Guided Tissue Regeneration
FACULTY OF DENTAL SURGERYWEST AFRICAN COLLEGE OF SURGEONSUPDATE COURSE IN CLINICAL DENTISTRY
05/02/2015
7/23/2019 6 Osseous Surgery.gtr
15/89
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
7/23/2019 6 Osseous Surgery.gtr
16/89
7/23/2019 6 Osseous Surgery.gtr
17/89
7/23/2019 6 Osseous Surgery.gtr
18/89
The Disease Process
7/23/2019 6 Osseous Surgery.gtr
19/89
The Disease Features
Bleeding on probing
Epithelial migration of the JE
Pocket formation
Suppuration
Pocket ulceration
Pockt deepens and anerobic environ
perpetuates inflammation
7/23/2019 6 Osseous Surgery.gtr
20/89
Intervention-Periodontal therapy
7/23/2019 6 Osseous Surgery.gtr
21/89
Intervention-Periodontal therapy
7/23/2019 6 Osseous Surgery.gtr
22/89
Ultimate Goal
To achieve healing and the restoration of
periodontal health.
7/23/2019 6 Osseous Surgery.gtr
23/89
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
7/23/2019 6 Osseous Surgery.gtr
24/89
Do we achieve this goal???
7/23/2019 6 Osseous Surgery.gtr
25/89
Defining terms
Repair - Epithelial adaptation
New Attachment formation
Regeneration
7/23/2019 6 Osseous Surgery.gtr
26/89
Is this the ultimate goal???
Restablishes a normal gingival sulcus
Arrest bone destruction
No gain in clinical attachment
No gain in bone height
Repair
7/23/2019 6 Osseous Surgery.gtr
27/89
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
Is this the ultimate goal???
7/23/2019 6 Osseous Surgery.gtr
28/89
Epithelial Adaptation
Close apposition without gain in height ofgingival attachment-Long junctional
epithelium to the tooth surface,
Epithelium Attachment
Is this the ultimate goal???
7/23/2019 6 Osseous Surgery.gtr
29/89
New attachment
Attachment of new PDL fibers into
new cementum on a tooth surface with
adequate bone support in areas previously
lost to disease.
Is this the ultimate goal???
If yes, how do we achieve it?
7/23/2019 6 Osseous Surgery.gtr
30/89
Achieving the goal
New periodontal ligament fibers
New cementum
Adequate bone support
In areas previously lost to disease.
New attachment
7/23/2019 6 Osseous Surgery.gtr
31/89
Obstacles!!
Fast-moving epithelial tissue in JE
JE migrates into the defect space
Cementum excluded
Periodontal ligament excluded
Result=long junctional epithelium
7/23/2019 6 Osseous Surgery.gtr
32/89
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
Is this the ultimate goal???
Is this the ultimate goal???
7/23/2019 6 Osseous Surgery.gtr
33/89
Addressing the obstacles
Difference growth rates of periodontal tissues
Rational for intervention:
== create an environment to allow for
differences in growth rate.
7/23/2019 6 Osseous Surgery.gtr
34/89
Addressing the obstacles
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.
7/23/2019 6 Osseous Surgery.gtr
35/89
Addressing the obstacles
Epithelium Attachment
Rational for intervention:
== aim to obtain a new attachment of actual
periodontal tissues like the PDL, cementum andalveolar bone.
7/23/2019 6 Osseous Surgery.gtr
36/89
Addressing the obstacles
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.
7/23/2019 6 Osseous Surgery.gtr
37/89
Addressing the obstacles
Close apposition without gingival attachment
Rational for intervention:
== Achieve close adaption with new periodontal
tissues to achieve new attachment.
7/23/2019 6 Osseous Surgery.gtr
38/89
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.
7/23/2019 6 Osseous Surgery.gtr
39/89
Rational for intervention
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
7/23/2019 6 Osseous Surgery.gtr
40/89
Guiding the way the periodontal tissues
regenerate in a way that produces predicable
results.
Rational for intervention
7/23/2019 6 Osseous Surgery.gtr
41/89
Guided Tissue Regeneration
7/23/2019 6 Osseous Surgery.gtr
42/89
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
7/23/2019 6 Osseous Surgery.gtr
43/89
Pioneer Human Experiment
Selectively isolating the gingiva from a healing
periodontal defect could result in regeneration
of the periodontal ligament and cementum.
7/23/2019 6 Osseous Surgery.gtr
44/89
7/23/2019 6 Osseous Surgery.gtr
45/89
7/23/2019 6 Osseous Surgery.gtr
46/89
Barriers timeline
Simple nonporous cellulose acetate filters Gold foil
Gore- tex--extremely inert and biocompatible
Expanded polytetrafluoroethylene (ePTFE)
Silicone button with pokerchip ePTFE
7/23/2019 6 Osseous Surgery.gtr
47/89
pokerchip epTFE---unique node and fibrilstructure for rapid cell integration.
over 90% air and internodal spaces of more
than 100 m
7/23/2019 6 Osseous Surgery.gtr
48/89
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
7/23/2019 6 Osseous Surgery.gtr
49/89
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
7/23/2019 6 Osseous Surgery.gtr
50/89
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
7/23/2019 6 Osseous Surgery.gtr
51/89
ePTFE membranes
7/23/2019 6 Osseous Surgery.gtr
52/89
Initial attempts
7/23/2019 6 Osseous Surgery.gtr
53/89
7/23/2019 6 Osseous Surgery.gtr
54/89
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
7/23/2019 6 Osseous Surgery.gtr
55/89
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.
7/23/2019 6 Osseous Surgery.gtr
56/89
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.
7/23/2019 6 Osseous Surgery.gtr
57/89
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
7/23/2019 6 Osseous Surgery.gtr
58/89
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.
7/23/2019 6 Osseous Surgery.gtr
59/89
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.
7/23/2019 6 Osseous Surgery.gtr
60/89
Indications for Guided Tissue Regeneration
Two or three wall vertical defects
Interproximal defects
Distal defects
Class II and class III furcation Defects
Gingival recession
7/23/2019 6 Osseous Surgery.gtr
61/89
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
7/23/2019 6 Osseous Surgery.gtr
62/89
Products for Guided Tissue Regeneration
First Generation:
Millipore filter
Expanded PTFE(Gore-tex)
Nucleopore membrane
7/23/2019 6 Osseous Surgery.gtr
63/89
Products for Guided Tissue Regeneration
Second Generation (resorbable):
Collagen membrane
Polylactic acid membrane (guidor)
Vicryl mesh
Cargile membrane
Oxidase cellulose
Hydrolysable polyester
7/23/2019 6 Osseous Surgery.gtr
64/89
Products for Guided Tissue Regeneration
Third Generation:
Resorbable materials + growth factors
7/23/2019 6 Osseous Surgery.gtr
65/89
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
7/23/2019 6 Osseous Surgery.gtr
66/89
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
7/23/2019 6 Osseous Surgery.gtr
67/89
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
7/23/2019 6 Osseous Surgery.gtr
68/89
7/23/2019 6 Osseous Surgery.gtr
69/89
7/23/2019 6 Osseous Surgery.gtr
70/89
7/23/2019 6 Osseous Surgery.gtr
71/89
7/23/2019 6 Osseous Surgery.gtr
72/89
7/23/2019 6 Osseous Surgery.gtr
73/89
8 mm pocket
7/23/2019 6 Osseous Surgery.gtr
74/89
Incision
7/23/2019 6 Osseous Surgery.gtr
75/89
Root defect exposed
7/23/2019 6 Osseous Surgery.gtr
76/89
Bio-oss in place
7/23/2019 6 Osseous Surgery.gtr
77/89
Membrane in place
7/23/2019 6 Osseous Surgery.gtr
78/89
Sutures in place
7/23/2019 6 Osseous Surgery.gtr
79/89
Dressing in place
7/23/2019 6 Osseous Surgery.gtr
80/89
A
B
C
D
D
E
7/23/2019 6 Osseous Surgery.gtr
81/89
Armamentarium
7/23/2019 6 Osseous Surgery.gtr
82/89
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
7/23/2019 6 Osseous Surgery.gtr
83/89
Things to note
Membrane should be completely absorbed eight weeks
Evaluate plaque, bleeding and tooth mobility indices
Allow 6 months before probing
7/23/2019 6 Osseous Surgery.gtr
84/89
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
7/23/2019 6 Osseous Surgery.gtr
85/89
Smooth & rough sides
7/23/2019 6 Osseous Surgery.gtr
86/89
Things to look out for!!
Swelling of surgical site
Thermal sensitivity
Excessive gingival bleeding
Dehiscence of flap
Gingival recession.
Root resorption or ankylosis
7/23/2019 6 Osseous Surgery.gtr
87/89
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
7/23/2019 6 Osseous Surgery.gtr
88/89
Success determinants
7/23/2019 6 Osseous Surgery.gtr
89/89
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.
Top Related