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Classic Lit Fall 2021 > Periodontal Regeneration > Flashcards

Periodontal Regeneration Flashcards

1
Q

New attachment

A

New attachment involves the embedding of new PDL fibers into new cementum and attachment of the gingival epithelium to a tooth surface previously denuded by disease

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2
Q

Reattachment

A

Reattachment is the reunion of epithelial and connective tissue with a root surface and refers to repair in areas of the root not previously exposed to the pocket such as after surgical detachment of tissues, traumatic tears of cementum, tooth fractures

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3
Q

Bone fill

A

Does not address presence or absence of new cementum, PDL, or alveolar bone histologically!
Refers to clinical assessment (Probe resistance and radiodensity)

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4
Q

Biodegradable vs Bioresorbable vs Bioabsorbable

A

Biodegradable refers to degrading WITHOUT PROOF OF ELIMINATION

Bioresorbable refers to degradation with ELIMINATION THROUGH NATURAL PATHWAYS (metabolism)

Bioabsorbable refers to DISSOLVING in body fluids with no enzymatic degredation required

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5
Q

What is GTR?

A

a surgical procedure with the goal of gaining new bone, cementum, and PDL attachment to a periodontally diseased tooth with the use of barrier membranes.

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6
Q

Karring et al. 1980a and b

A

No barrier used - gingival contact caused resorption - No CT attachment (bone and gingiva fail to induce CT attachment)

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7
Q

What was the first GTR in human?

A

Nyman et al. 1982b

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8
Q

Nyman et al. 1982a and b

A

used Milipore filter membrane
New cementum inserted collagen fibers at apical end
CT adhesion with no new cementum at coronal

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9
Q

Gottlow et al. 1984

A

Milipore filter VS Flap alone

Milipore filter had considerably more attachment

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10
Q

What functions do the barrier membrane provide?

A

Space Maintenance
Epithelial Exclusion
Wound Stabilization

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11
Q

How many cell types are competing for the healing space in GTR?
What are they?

A 
5
Epithelial cells
Connective Tissue Fibroblasts
Alveolar bone cells
PDL cells
Cementoblasts
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12
Q

What happens to an exposed root surface when it is repopulated with different cell types?

A

Caffesse & Becker 1991

Epithelial: Long junctional epithelium
Connective tissue: root resorption
Osseous: ankylosis
PDL: regenerated attachment

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13
Q

Why is Nyman 1982 a landmark study for GTR?

A

Proof of new cementum formation with inserting collagen fibers 3mo after GTR
Showed concept of excluding soft tissue (CT and epi) to allow multipotent PDL stem cells to form new attachment

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14
Q

Wang & Boyapati 2006

A

PASS Principle for predictable GBR (GTR)

Primary wound closure
Angiogenesis
Space maintenance/creation
Stability of the wound

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15
Q

What do each principal of PASS provide?

A

Primary wound closure: facilitate tissue maturation

Angiogenesis: cells which release growth factors/cytokines/undifferentiated cells to repopulate

Space: bone graft/membranes/CAF/tenting screws - space for bone formation

Stability: necessary for wound healing/clot formation/barrier fixation

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16
Q

How many methods of regeneration are there? what are they?

A

5

Interdental denudation
Coronally Advanced Flap
Grafts
GTR (Membrane)
Biologic Agents
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17
Q

What biomaterials are used in GTR?

A

Membranes
Grafts
Biologic agents

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18
Q

What options are there for Non-Resorbable Membranes?

A 
Cellulose Ester Millipore Filter
ePTFE (Gore-Tex)
dPTFE
Titanium-reinforced ePTFE
Titanium Mesh
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19
Q

What does e/dPTFE stand for

A

Expanded/Dense Polytetrafluoroethylene

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20
Q

Pore size of Cellulose Ester Millipore Filter

A

0.22µm

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21
Q

Pore sice for ePTFE

A

0.45µm

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22
Q

Pore size for dPTFE

A

0.2µm

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23
Q

For Non-resorbable membranes - why do we get a thin layer of soft tissue on the inside of the membrane?

A

Foreign body reaction

Micro-movement induced fibrous encapsulation

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24
Q

What characteristics are membranes made based on?

A 
Biocompatibility
Maintaining Vascularity
Cell occlusion (Epi/CT)
Tissue Integration
Cell: Migration, Attachment, Proliferation, Differentiation at membrane substratum
Bacterial resistance
Space-making capability
Clinical handeling
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25
Q

What function(s) to pours provide?

A 
Tissue integration (mechanical support)
Bacterial resistance (smaller pour size = less bacteria)
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26
Q

What classical study used an ePTFE membrane? Description/Results?

A

Dahlin et al. 1990

7 Monkeys - healing of Max and Mand bone defects
Bio-inert ePTFE with pour size too small for Epi/CT cells (but not bacteria***) created a secluded environment for osteogenesis to take place.

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27
Q

How many borders does an ePTFE membrane have? What are they and what do they do?

A

2

Coronal (clot formation, collagen fiber penetration, delay epi migration)
Occlusal (cell occlusion, space maintenance)

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28
Q

What is the downside of ePTFE? Citation

A

Larger pour size allows for bacterial invasion

Lang et al. 1994 found 30-40% membrane exposure associated bacterial infection

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29
Q

Name 2 studies that discuss impact of pore size in ePTFE

What do they say?

A

Larger pore size of ePTFE may allow bacteria to penetrate easier and be the reason for the greater infection rate vs dPTFE

Selvig et al. 1990
Lang et al. 1994 - 30-40% exposure associated infection

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30
Q

When should a Titanium-reinforced ePTFE be used? Citation

A

Wide and/or Non-supportive defects

Cortellini et al. 2000

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31
Q

When should Titanium Mesh be used

A

More for GBR

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32
Q

What studies investigated the effect of pore size on GTR?

A

Zellin & Lindhe 1996

Wikesjo et al. 2003

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33
Q

What study compared pore sizes in non-resorbable membranes?

A

Test 3 different pore sizes

20-25µm and 100µm group had increased rate of osteogenesis vs 8µm
(higher permeability and tissue integration)

Zellin & Lindhe 1996

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34
Q

Wikesjo et al. 2003

A

Tissue occlusion does not appear to be a critical determinant, but may be a requirement for GTR

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35
Q

What options are there for resorbable membranes?

A

Collagen-based
Polymer-based
Allografts (Acellular Dermal Matrix - Amnion-Chorion)

36
Q

What is the main difference between Cross Linked and Non-Cross Linked Collagen Membranes?

A

Degradation time

37
Q

How do collagen membranes degrade?

A

Host Collagenases
MMP1 (Fibroblasts)
MMP8 (Macrophages, PMNs, Neutrophils - Inflammatory)
MMP13 (Osteoclasts)

38
Q

How are Cross Linked Collagen membranes, cross linked? What effect does it have?

A

Usually w/ Glutaraldehyde but can be ribose cross linked (OSSIX)
Glutaraldehyde is released during the degradation process, delaying epithelial cell migration - leading to slower degradation - more time for selective cell re-population - also increased inflammatory/foreign body response though

39
Q

How long does it take for collagen membranes to resorb? Citation

A

3-4weeks (Paul et al. 1992)

Longer for cross-linked

40
Q

What are the pros and cons of cross-linked collagen membranes? Citation

A

Pros: Longer resorption time leading to longer time excluding epi/CT cell invasion

Cons: RR of 1.43 (95% CI: 0.85-2.39) (NSSD) between the cross linked vs non-cross linked, with a marginal tendency towards higher exposure in the cross-link membrane group (Garcia et al. 2017 systematic review)

The glutaraldahyde makes it too rigid! (Dr. Wang)

41
Q

What are Polymer-based Membranes made of? (In general and specifically)

A

Chemically synthesized aliphatic polyesters.

Polylactide (PLA), Polyglycolide (PGA), Trimethylcarbonate

42
Q

What is the benefit of polymer based membranes?

A

Better mechanical stability vs collagen

43
Q

How are polymer based membranes reorbed? What does it result in?

A

Hydrolytic activity (Krebs cycle) - Acidic biproducts released - may cause fibrous layer??

44
Q

What is the degredation rate of Polymer membranes dependent on?

A

pH, presence of mechanical strains, enzymes, bacterial infection, COMPOSITION

45
Q

Which material resorbs slower for polymer membranes? (citation) how can it be modified?

A

PLA is more stable than PGA (Resorbs slower) (Tatakis et al. 1999)
Adding crosslinked D-Lactide or Glycolide allows faster degradation

46
Q

What membrane is PLA alone? How long do these take to resorb?

A

PLA alone does not appear to be available???

Poly-D,L-Lactide: 6-12mo
Poly-D,L-Lactide, Co-Glycolide: 5-6mo
Jiaolong Wang et al. 2016

47
Q

What is a CON of PLA or PLGA membranes?

A

Although PLA- and PLGA-based membranes are non-cytotoxic and biodegradable, the releases of oligomers and acid byproducts during degradation may trigger inflammation reactions and foreign body response in vivo (Zwahlen et al. 2009, COIR, RCT)

48
Q

What is ADM composed of?

A

Human, porcine, or bovine skin

49
Q

What can ADM be used for? citation

A

As an alternative to autogenous KG - Build KG around implants/teeth or for root coverage (de Andrade 2007)

50
Q

What does lit say about ADM and infection?

A

May not be colonized sitnificantly by periodontopathic bacteria - even when exposed completely, still incorporated into host and heals (de Andrade 2007)

51
Q

What is Amnion Chorion derived from?

A

Human placenta - inner and outer membrane (amnionic membrane - chornionic membrane)

52
Q

CLINICAL benefits of Amnion-Chorion membranes? Citation

A

Lack stiffness - easily adapted to infrabony defects - no trimming/suturing needed - less surgical time/flap reflection
(Szurman et al. 2006)

53
Q

Healing benefits of Amion-Chorion membranes (citation)

A

Contain growth factors (PDGF-AA/VEGF (vascular endothelial…))
Could enhance wound healing and reduce bacterial contamination decreasing risk of exposure
(Gulameasbasse et al 2020)

54
Q

Compare and contrast resorbabl vs. non-resorbable membranes

A

NRM: Non-resorbable membrane
RM: Resorbable membrane

Space making: NRM better

Bac resistance: NRM better

Cell attachment/prolif: RM better

Biologic properties:
NRM: biocompatible/Bio-inert/requires removal
RM: biocompatible/bio-INTERACTIVE/biodegradable

Post op exposure: NRM MORE

55
Q

What are the disadvantages of non-resorbable membranes?

A

2nd surgery
High membrane exposure
More gingival recession

56
Q

Can resorbable or non-resorbable tolerate exposure better?

A

NON-RESORBABLE (tolerate better - but more often)

57
Q

What rand of particle size should bone grafts be? (citation)

A

250-750microns

Kathagen et al. 1984

58
Q

What negative effects can particle size cause? what size causes these issues?

A

<125microns: Foreign body reaction

>1000microns: sequestration
Kathagen 1984

59
Q

How do bone grafts help in GTR? Citaion

A

Maximize regenerative potential via osteoinduction, osteoconduction, and clot stabilization (Cortellini & Tonetti 2015)

60
Q

Where can Autograft be harvested from?

A 
tuberosity
ramus
exostoses
alveolar ridge
mental symphysis
post-extraction sites
edentulous ridge
61
Q

Optimal time to take auto from extraction socket

A

8-12weeks (Evian et al 1982

62
Q

What is different from tuberosity vs ramus/chin graft?

A

Tuberosity is highly cancellous

Chin/Ramus are monocortical

63
Q

Buck et al. 1989/1990

A

Screening and freezing Allograft reduces risk of HIV transmission to 1/8million

64
Q

What properties do allografts have? (ciotation)

A

Mostly osteoconductive, except DFDBA which may have osteoinductive abilities (Wang & Cooke 2005)

65
Q

What is the difference between DFDBA/FDBA

A

FDBA looses cell viability and acts as a scaffold

DFDBA has exposed BMPs that can induce cell recruitment

66
Q

How does DFDBA perform in GTR procedures?

A

Series of studies with DFDBA vs no graft in GTR
DFDBA had new attachment apparatus, bone, and cementum (TRUE NEW ATTACHMENT)
Bowers et al. 1989

67
Q

What properties does Xenograft have?

A

ONLY OSTEOCONDUCTIVE serves as a scaffold

68
Q

Which is better for GTR, Xenograft or Allograft? ()citation)

A

NSSD - Richardson et al. 1999

69
Q

What are examples of Alloplast?

A

Hydroxyapatite, beta tricalcium phosphate, bioactive glass, some polymers

70
Q

What are the 3 processes for sterilizing allograft?

A

Freezing/Ethonol bath (FDBA)
Freezing/Ethanol bath/HCl (DFDBA)
Solvent-dehydrated (Human HA)

71
Q

What characteristic dos Puros have?

A

Osteoconductive (Human HA)

72
Q

What are the most common biologics used today?

A

PRP ( Platelet rich plasma)
rhPDGF (recombinant human platelet derived growth factor)
EMD

73
Q

What is PRF/PRP composed of?

A

PDGF, I-LGF, VEGF, TGF-b

74
Q

What is the MOA of PRP/PRF?

A

Provides GFs and Platelets

75
Q

Indications for PRF/PRP

A

Recession coverage/barrier membrane/Sticky Bone

76
Q

What is the MOA of rhPDGF?

A

Causes Chemotaxis and Cell Proliferation

77
Q

What are the indications for rhPDGF?

A

Intrabony defects
Furcations
Recession
in combo with allograft/xenograft

78
Q

What does rhPDGF have FDA approval for?

A

Intrabony defects
Furcations
Gingival recessions

79
Q

What is EMD composed of

A

90% Amelogenin

10% includes tuftelin, ameloblastin, enamelin and enamel proteases.

80
Q

What is the MOA of EMD?

A

it induces cementogenesis

81
Q

What are the indications for EMD?

A

Intrabony defects
Class II Furcations
Recession coverage

82
Q

What is EMD FDA approved for?

A

Intrabony defects

Optimizing tissue height in esthetic zone

83
Q

What is the MOA of BMP?

A

Increased proliferation/mineralization

Expression of alkaline phosphate and osteocalcin

84
Q

Indicaitons for BMP

A

systemic/anatomic conditions where successful bone regen cant be achieved with conventional grafts
NOT WITH DBBM

85
Q

What is BMP FDA approved for?

A

Sinus augmentation

Socket preservation

86
Q

What study is important when discussing regeneration using bone graft?

A

Series of histological studies by Bowers in 1989

87
Q

Describe histological studies on regen using bone graft

A 
Bowers 1989 (series)
Used DFDBA vs no graft in a submerged and non-submerged environment

DFDBA had more new PDL, bone and cementum
Regeneration only in the submerged group

Classic Lit Fall 2021 (29 decks)

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