Perio Regeneration 2 Flashcards
What is Compartmentalization? Purposed by who?
Melcher 1976
Cells of the periodontium divided into 4 compartments
Epithelial Cells
Connective Tissue Cells
Alveolar Bone Cells
PDL Cells
How does barrier membrane compare to flap alone?
Gotlow 1984
Millipore vs Flap
SSD: More attachment with Milipore filter
What factors influence success of GTR?
Kornman & Robertson 2000
Bacterial contamination
Innate wound healing potential
Local site characteristics
Surgical technique
What patient factors should be considered before performing GTR?
Oral hygiene/Patient compliance
Smoking status
How does oral hygiene effect GTR? Citations
Cortellini et al. 1996
1yr
Patients w/ FMPS >10% had worse outcomes and had attachment loss over time
What effect does smoking have on GTR? Citations
Non-Smokers have 2.5x more CAL gain (2.1 vs 5.2)
(Tonetti et al. 1995)
Smokers: 0.8
Non- Smokers: 1.9
(Hietz-Mayfield et al. 1998)
How does oral hygiene effect GTR Long term?
Cortellini & Tonetti 2015
96% success for 15yrs with optimal OH and recall
Cortellini 2020
10yr follow up study - 88% success of treating SEVERELY hopeless teeth - Economically better
How does Mobility influence CAL gain after GTR
Fleszar et al. 1980
Inverse relationship between CAL gain and mobility after PERIODONTAL SURGERY (More for GTR probably)
Cortellini & Tonetti 2015
Limited mobility (<class II-III) is essential for early clot stability and overall success
Schulz 2000
Presplint: 5.1
Postsplint: 3.5
No-splint: 1.7
When should you splint?
Schulz et al. 2000
Pre-splint: 5.1mm CALgain
Pos-splint: 3.5mm CALgain
Non-splint: 1.7mm CALgain
What study found conflicting results for splinting?
Trejo and Weltmann - NSSD between splint/non-splint
How does depth/width/walls of defect effect success?
Deep/Narrow/3-wall:
Protect/Stabilize wound
Keep regenerative cells in close approximation
Wide/Shallow/non-contained:
Risk coagulum displacement/wound instability
(Cortellini and Tonetti, 2000)
What angles represent Narrow and Wide? (Citation)
Narrow: < 25˚ (Cortellini & Bowers 1995)
Wide: > 37˚ (Tonetti et al. 1993)
What depth delineates Shallow/Deep?
Shallow: _<_4mm
Deep: >4mm
What wall defects have the best results?
3 wall (Becker & Becker)
Who classified Infrabony Defects?
Goldman et al. 1958
What is the flowchart for predictability? Citation
What are some findings of the AAP Regeneration Workshop?
Class I Furcation can be maintained without regeneration
Class II Should be Regenerated
Class III has limited evidence
Combined approach is better than mono-therapy (ie. use graft + membrane etc.)
What kind of local factors can present an issue during GTR? What should be done with them? Citation
Bifurcation Ridges
Restorations w/ apical margins
Enamel pearls
Crowns
CEPs
Palatoradicular grooves
Identified and removed
Mardam-Bey et al. 1991
If a CEP/enamel pearl/Restoration/etc is present, and you remove it before GTR, how is the success rate affected by its initial pressence? Citation
it is not affected! Tsao et al. 2006
How have the theories around GTR evolved? Citations
Competition theory (Melcher 1976)
Blood Clot Stability (Wikesjo 1990)
How does Wikesjo et al. 1990 impact the understanding GTR?
Clot adheres to dentin via adsorbtion of plama proteins
No space for epithelium to migrate apically once there has been adhesion of the clot
Periodontal regeneration takes place apical to the most coronal adhesion of the clot
What was the first flap for soft tissue preservation in GTR?
How is it done and what is the disadvantage?
Takai 1985
Papilla preservation technique
semilunar incision through palatal IDP - intrasulcular buccal - feed papilla through facial
How much space is needed for the Papilla Preservation Technique?
>2mm interproximally
What are the different preservation techniques? in order
Papilla preservation technique
Modified papilla preservation technique
Simplified papilla preservation technique
Minimally invasive surgical technique
Modified minimally invasive surgical technique
Entire papilla preservation technique
Non-incised papilla surgical approach
How does MPPT perform in comparison to other incision techniques? Citation
Cortellini et al. 1995
Significantly more attachment gain vs conventional GTR or Flap
5.2 + 2.2mm vs 4.1 _+_1.9mm vs 2.5 + 0.8mm
Improved primary closure
73% at 6wks
What incision design would you use if there was <2mm interproximal space? How is it designed? Citation
Crotellini et al. 1999
Simplified Papilla Preservation Technique
Buccal: M Line angle to under contact point
Palatal/Lingual: Intrasulcular
How does the SPPT perform?
4.9 + 1.8mm attachment gain
67% primary closure
What technique could you use if you have an isolated, deep defect in the esthetic zone?
Minimally Invasive Surgical Technique
What is MIST? Citation
Basically a SPPT incision, except only include 1 papilla
Cortellini & Tonetti 2007
What is the Modified MIST? When do you use? Citation
MIST, except only incise on 1 side of the tooth (buccal or lingual)
Microscope - when only ⅓ of the interproximal has the defect
Cortellini & Tonette 2007
What is the EPP? Citation
Entire Papilla Preservation Technique
Aslan et al. 2020
Vertical release on the opposite side of the tooth from the defect (same tooth)
Intrasulcular
Tunnel under defect associated papilla
What is the incision called that only has a horizontal incision in the mucosa? Citation?
NIPSA
Non-Incised Papilla Surgical Approach
Rodriguez et al. 2018
How often do membranes get exposed in GTR? Citation?
70-80%
Murphy et al. 1995
What happens if a membrane gets exposed? Failure? What should you do?
Unlikely to cause failure if plaque is controlled in the area
Antimicrobial rinses, more frequent recalls, systemic antibiotics
Bone gain with exposure?
Trombelli et al. 1997
6mo post op:
With exposure: 2.2mm
Without exposure: 4.1mm
How does exposure impact GTR in teeth vs GBR in implants?
Machtei et al. 2001
Meta-analysis of Furcation vs Infrabony defects vs GBR implants
Membrane exposure had a major negative impact on GBR but minimal effect on GTR in teeth
<1mm difference in GTR groups
6x greater gain in non-exposed GBR group
How can we assess GTR outcomes? Pros/cons of each
Clinically (PD/CAL/Bone sounding - no regeneration assessed)
Radiographically (underestimates bone loss/radiodensity depends on graft material and healing time)
Re-entry (second surgery needed - Attachment type?)
Histology (Gold standard - removal/biopsy required)
How does OFD vs Bone Graft vs Membrane (GTR) compare?
Laurell 1998 meta analysis
Bone fill:
- 1
- 1
- 2
do-ray-me
CAL
1-2-4
How does healing look histologicallly from GTR?
Most likely - Most apical portion has true regeneration, and repair in the coronal
Similar to Stravapoulus et al. 2011
What should be done before completing a GTR procedure on a patient?
Cause-related therapy
SRP - OHI - Motivation
What is the critical gap concept and what size is it? citation
The gap beyond which incomplete healing occurs without use of a graft
0.5-1.25mm - Botticelli
Why is the research on the critical gap smaller than the real critical gap?
Was done on the buccal aspect of teeth - in between teeth we need space for PDL (0.5-0.8mm) so at least 1mm
Distal w/ no tooth: >2mm use membrane
What is the difference between Guided Bone Regeneration and Protected Bone Augmentation?
Protected Bone Aug is using titanium mesh! does not have cell occlusion, just protects the space
