Regenerative Surgery

Question 1

What is the EFFICACY of the different regenerative treatment options in FURCATIONS

Answer 1

F.I. type 3 showed very little efficacy (__?__) while F.I. type 1 demonstrated satisfying results w/ NST (__?__).
F.I. type 2 benefits the most of “regenerative ttm” (which? OFD? memb+bone? EMD?)
and shows better results in mandibular molars rather than maxillar (Avila-Oritz 15; Reddy 15; Sanz 15; Jepsen 2020)

Type II furcations show significant improvement 6m after access flap surgery (Graziani 15) and could be successfully treated with regenerative ttm, especially with a combined regenerative approach (Reddy 2015)

McGUIRE 1996 O.R. 1.7, DONNEWITZ 2016, NIBALI 2016 demonstrated a worst prognosis for F.I., but mostly with F.I. 3&2.
Nibali 2016: RR of 1.7 (type II vs I), 1.8 (III vs II) and 3.1 (III vs I) with statistical significance

Question 2

List the different regenerative techniques and the surgical differences that exist between them

Question 3

Describe the advantages that a Minimally invasive approach provides vs conventional regenerative treatment

Question 4

Is there any technique superior to another?

Question 5

Situations in which the use of EMD is justified in periodontal regeneration

Question 6

Situations in which the use of EMD IS NOT justified in periodontal regeneration

Question 7

What is the Long-term STABILITY of GTR? (results, survival, factors)

Question 8

IS ALLOGRAFT SUPERIOR TO XENOGRAFT???

Answer 8

De Risi 2015 S.R.&M.A.
Highest value regarding bone% produced at 3m by Allograft (54.4%), while the lowest at 5 months, by Xenografts (23.6%)

Question 9

Why haven’t you splinted the regenerated tooth

Answer 9

Cortellini 2015 (mobility type 2/ not)

Question 10

GTR vs. OFD

Answer 10

Graziani 2011 and Nibali 2020 Meta-Analysis:
CAL gain (1.34 mm; 0.95-1.73) compared with
open flap debridement alone. Both enamel matrix derivative (EMD) and guided tissue regeneration (GTR) were superior to OFD alone.

Kinaia 2011
GTR more effective vs OFD in reducing V-PD and gaining V-CAL and in gaining vertical and horizontal bone

GTR significantly superior (>1mm) vs OFD in Vertical-PD, Vertical & Horizontal CAL gain and BONE FILL.
Avila-Oritz 2015
Jepsen 2002
Murphy KG 2003

Question 11

GTR vs. EMD?

Answer 11

Venezia 2004 literature .rev.&Meta-analysis
EMD better results than GTR (~0.5mm CAL gain, PD reduc. and Rec.reduc.)

Matarasso 2015 Sys.Rev.&Met.Anal
EMD with bone graft improves results in terms of CAL gain and PD reduction.

Jepsen 2004
* EMD: Horizontal PD reduc. 2,6 ±1,8mm
* GTR: 1,9±1,4mm (1,0-2,8mm)
- Complete closure of F.I.: EMD 8/45 & GTR 3/45.
* Less pain/inflamm. W/ EMD.

Question 12

Enamel projections?

Answer 12

Machtei E. 1997
Prevalence of enamel projections in molars con W/ F.I. : 62,5% -82,5%.
- Prevalence mandibular Molars vs maxilar (2:1)
- Prevalence: 25% 1st mandibular molars & 37% 2nd mandibular molars.
- Males (77.4%) vs. females (20.4%).

Moskow & Canut 1990:Enamel projections are mostly frequently found at buccal furcations of 1st molars.

McGuierre & Nunn 1996
Bowers 1979
* High prevalence e in periodontal pt.
* Risk Factor de for CAL progression
* Influence over molar’s prognosis:
* Causes: Inflammation, Caries and less favorable T/ response to Perio-T/ vs monoradicular teeth.
* Higher risk of tooth loss.

Question 13

F.I. Prognosis tooth loss

Answer 13

Affecting the prognosis:
- - - - - -
McGuire & Nunn 1996 -> OR:1.7
Pretzl et al. 2008
Salvi et al. 2014
Dannewitz et al. 2016 -> HR:4.6
Tonetti et al. 2017
Nibali et al. 2016 RR of 1.7 (type II vs I), 1.8 (III vs II) and 3.1 (III vs I) with statistical significance

Question 14

F.I. D/x

Answer 14

Hamp 1975: grades I-II-II

Carranza & Takei 1990: since bone loss is minimal, the incipient lesion may not be seen RX in most instances

Diff.D/
1. Pulpal pathosis: If signs of healing of a furcation defect fail to appear within 2 months of endodontic treatment, the furcation involvement is probably associated with marginal periodontitis.
Lesion in the inter-radicular space
2.Periodontitis
3.Trauma from occlusion: If the defects seen within the root complex are of “occlusal” origin, the tooth will become stabilized and the defects disappear within weeks following correction of the occlusal overload

Question 15

F.I. Treatment Prognosis

Answer 15

Huynh-Ba et al. 2009
GTR, bone graft: 62–100% after a period of 5–12 years
Non‐surgical furcation therapy: 90.7–100%, observation period of 5–12 years. Tooth survival in molars class I F.I. (74% y) 99– 100%;
Molars class II F.I. was 95% and class III F.I. was 25%
OFD / ORS (i.e. flap with or without osseous resection, gingivectomy/gingivoplasty, but not including furcation odontoplasty): 43.1–96% at the end of an observation period of 5–53 years
Root resection (i.e. root resection or root separation): 62–100% after an observation period of 5–13 years. Reported
complications root fractures and endo failures.

Question 16

Factors influencing furcation defect GTR?

Answer 16

Bowers 2003 & Tsao 2006
Smoking: Signifcant residual F.I.-II 62% vs 14%
Radicular divergence: +favorable when ≤3mm 90% (vs ≥4mm 60%) furcation closure
H-PD: ≤4mm 80% (vs ≥5mm 50) furcation closure
Provate clinic vs Uni: NN significant
1st vs 2nd molars: NN significant
Memb exposure: NN significant
Buccal vs Lingual furcation: NN significant.