Osseous Surgery-Regeneration

Question 1

Osseous Regeneration
 Objectives of Bone Replacement
Grafting
(2)

Answer 1

 Regeneration* of lost periodontium
new bone, cementum and
periodontal ligament
 Reduce or eliminate the periodontal
pocket

Question 2

 Autograft:

Answer 2

tissue transferred from one site
to another in the same individual

Question 3

 Allograft:

Answer 3

tissue transferred between
individuals of same species

Question 4

 Alloplast:

Answer 4

inert material used for graft

Question 5

 Xenograft:

Answer 5

tissue transferred between
individuals of differing species

Question 6

 Composite:

Answer 6

combination of grafts

Question 7

Bone Replacement Grafts
 Indications for grafting
(5)

Answer 7

 Deep vertical defects
 Esthetic considerations
 Teeth critical to prosthesis
 When anatomy precludes other
procedures
 Guided Tissue Regeneration (GTR)

Question 8

Contraindications
for grafting
(3)

Answer 8

 Poor plaque
control
 Medically
compromised
 Poor
maintenance
compliance

Question 9

Bone Replacement Grafts
 Advantages of grafting
(3)

Answer 9

 Restores lost periodontal tissue
 Maintains teeth in healthy functional
state
 Enhances long term prognosis of
teeth

Question 10

Disadvantages of grafting
 (2) sensitive
 — (?)
 May require — (?)
 Predictability?
 Requires —
 Longer, more frequent — needed
 — sometimes required
 Success decreases significantly in — and is —dependent

Answer 10

Technique and material
Expensive
two surgeries
Unpredictable
ideal wound closure
post-op care
Second surgical site
furcations, defect

Question 11

Osteogenic-

Answer 11

viable osteoblasts are
transplanted

Question 12

 Osteoconductive-

Answer 12

scaffold for bone
formation

Question 13

 Osteoinductive-

Answer 13

release of material to
induce bone formation

Question 14

 Osteoproductive-

Answer 14

production of bone by
a biologic mechanism?

Question 15

Bone Replacement Grafts
 Healing Sequence
(5)

Answer 15

 Incorporation (clot formation)
 Revascularization
 Resorption of graft material with release
of factors (BMP) to induce bone
formation
 Bone formation
 Bone remodeling and maturation

Question 16

Osseous Defects
 Suprabony versus Infrabony defects
 If the distance between the roots of the
teeth is ≥– mm then the defects will be a
vertical defect (amount of cancellous bone
present).
 If the distance is less than – mm then
horizontal bone loss will occur

Answer 16

2.5
2.5

Question 17

Osseous Defect
Classification-Review
 Infrabony: apical to the alveolar crest
(4)

Answer 17

 One wall-(can be a hemiseptum)
 Two wall-(crater-the most common
defect)
 Three wall-(true intrabony defect)
 Combination-(of any of the above)

Question 18

Success in regeneration is defect
dependent:
(4)

Answer 18

 Best success seen in three-wall defects
 Next are two-wall defects
 Then are one-wall defects
 Suprabony defects (horizontal bone loss)
have little to no success

Question 19

Bone Replacement Grafts
 Graft complications
(5)

Answer 19

 No regeneration**
 Sequestra
 Root resorption (rare)
 Donor site problems (at second site)
 Infection (less than 1%)

Question 20

Grafting Variables
 (2) at time of surgery
 Local — before surgery
 — design*
 — penetration*
 — of graft material
 — treatment or modification
 Use of —
 — and graft success*
 — and graft success

Answer 20

Pre-scaling or scaling
drug delivery
Flap
Intramarrow
Hydration
Root
antibiotics
Endodontics
Smoking

Question 21

Intraoral Bone Sources
 Intraoral
(4)

Answer 21

 Cortical bone chips (no longer used)
 Osseous coagulum**
 Healing extraction socket (timing very
important)
 Chin or ramus block graft

Question 22

Intraoral Bone Sources
 Extraoral
(2)

Answer 22

 Iliac crest
 Ribs

Question 23

Allografts
 Types
(3)

Answer 23

 Freeze-dried bone allograft (FDBA)
 Demineralized freeze-dried bone allograft
(DFDBA)
 Solvent-treated (Puros®)

Question 24

 Safety-

Answer 24

shown in HIV/AIDS donors

Question 25

 Inductive ability -

Answer 25

amount of BMP available?

Question 26

 Hydration-

Answer 26

materials and amounts

Question 27

 Controversies-

Answer 27

resorption of graft?, BMP

Question 28

Alloplasts  Types (4)

Answer 28

 Calcium Sulfate (CapSet ®)  Calcium Phosphates resorbable  HTR®  Bioactive glass ceramics

Question 29

 Calcium Phosphates (2)

Answer 29

 Beta tri-calcium phosphate (resorbable)  Hydroxyapatite (resorbable and non-

Question 30

CaSO4 /Regeneration Rationale for adding calcium sulfate to FDBA (2)

Answer 30

* Binds bone particles to prevent washout * Accelerates bone formation by: Enhancement of BMP Providing a source of Ca ++ ions to aid in mineralization Sottasanti 92

Question 31

Skipped CaSO4 (3)

Answer 31

* Composite animal graft success: Kim, 98, with histology * Animal graft success: Kim, 98 with histology; MacNeill 99 with histology * Composite human graft success: Pepelassi, 91; Orsini 01: composite grafts = GTR; Kim 98; Maragos 02; Aechelmann-Reddy et al, 04; Harris 04 SRM Case of Dr. Mark Blue SRM SRM

Question 32

Bioactive glass is composed of

Answer 32

silicon dioxide (45%), calcium oxide (24.5%), sodium oxide (24.5%), and phosphorus pentoxide (6%) “...when implanted in vivo the pH of the local environment increases >10, and a silicon- rich gel is formed on the bioactive ceramic surface with the outer layer serving as a bonding surface for osteogenic cells and collagen fibers"

Question 33

One brand has a particle size from ---um Other brand has a particle size of ---um * ...”formation of hollow calcium phosphate growth chambers occurs with this size because phagocytosing cells can penetrate the outer silica gel layer and resorb the gel. This leads to formation of pouches where osteoprogenitor cells can adhere, differentiate and proliferate.

Answer 33

90-710 300-355

Question 34

Bioactive Glasses Reported in several articles to have: (4)

Answer 34

* superior manageability * hemostatic properties * osteoconductive * may act to retard epithelial downgrowth

Question 35

SKIPPED Bioactive Glasses (8)

Answer 35

Ong 98: contralateral defects vs flap debridement (-) Froum 98: versus flap debridement (+) Lovelace 98: paired defect study vs DFDBA (+) Hall 99: animals/implants/vs DFDBA (-) MacNeill 99: (animal study) (-) Nevins 00: (histology: no regeneration) Froum 02: (histology: no regeneration) Series of case reports or clinical studies without controls that reported advantage of bioactive glass Sohrabi 12: meta-analysis: bioactive glasses superior to flap debridement (.6mm in CAL gain) (+

Question 36

Xenografts  Types (3)

Answer 36

 Bovine bone (BioOss®)  Bovine bone with cell-binding peptide-15 attached (PepGen®)  Fetal pig enamel matrix derivative (Emdogain®) to induce cementogenesis and bone formation

Question 37

Skipped Regeneration with Enamel Matrix Proteins Positive Effects with use: (6) Rasperini 0

Answer 37

* Yukna and Mellonig 00: human histology showed inconsistent and variable results in ten patients * Sculean 03: 2 pts, human histology showed +regeneration; Sculean 05: human histology * Cochran 03: animal histology, +regeneration * Greenstein 00: review * Clinical success seen in Okuda 00; Heden 00; Camargo 01; Tonetti 02; Sculean 02,03,05,06;

Question 38

Skipped Regeneration with Enamel Matrix Proteins No effect with use: (6)

Answer 38

* Sculean et al, 03: used with non-surgical therapy * Donas et al, 03: EMP vs F/C * Vandara et al, 04: EMP vs F/C * Regazzini et al, 04: EMP with and without GTR, control; animal study with histology * Rosing et al, 05: EMP vs F/C * Hoidal et al 08: EMP with/without DFDBASRM

Question 39

Guided Tissue Regeneration: GTR Membrane will provide

Answer 39

epithelial exclusion

Question 40

SKIPPED Guided Tissue Regeneration (6)

Answer 40

* Interdental Denudation (Pritchard) * Soft Tissue Grafts over Osseous Grafts (Ellegard) * Citric Acid Application (Loma Linda Studies) * Micropore® Filter (Nyman) * Gore-Tex® (Non-Resorbable) Membranes * Resorbable Membranes

Question 41

Newer Techniques  Platelet Rich Plasma (PRP) (concentration of growth factors)  Addition of synthetically-produced Growth Factors

Answer 41

 Recombinant human Platelet Derived Growth Factor (rhPDGF) added to beta tricalcium phosphate (e.g. GEM 21 ®)  Recombinant Bone Morphogenetic Protein (rBMP) added to beta tri-calcium phosphate (e.g. Infuse ®). Edentulous ridges ONLY

Question 42

Skipped Platelet Rich Plasma Concentrate (3)

Answer 42

Anunziata et al, 05: PRP in vitro stimulated PDL and fibroblast cell line growths and keratinocyte growth rate was inhibited. Hanna et al, 05: split mouth clinical trial with matched defects of 13 pts. PRP improved results significantly. Fabbro et al, 12: systemic review and meta- analysis; PRP may exert a positive adjunctive effect with graft materials, but not with GTR

Question 43

Skipped Current Trends in Regeneration Platelet Rich Plasma Concentrate (5)

Answer 43

* Okuda et al, 03 * 20 healthy patients had blood taken and PRP performed * Platelets increased 283% compared to control * 182 ng/ml of PDGF which is 440% increase * 141 ng/ml of TGF-beta which is 347% increase

Question 44

Skipped Current Trends in Regeneration rhPlatelet Derived Growth Factor or rBMP (5)

Answer 44

Carmello 03: 4 pts, rhPDGF with DFDBA; histology showed +regeneration Miranda et al, 05: rBMP-2 used in baboon alveolar ridge defects versus control and produced a two fold +increase in width and +bone density. Nevins et al, 05: multicenter study using rhPDGF-BB in 180 pts. At six months a 57% radiographic bone fill vs 18% for the control McQuire et al, 06: followed four pts of previous study at 18-24 months and same results found as at one year. Mellonig et al ,09: histology for four pts with treated furcations, variable results