Step 3, Restorstive & SPT

Question 1

IS ALLOGRAFT SUPERIOR TO XENOGRAFT?

Answer 1

De Risi 2015 S.R.&M.A.
Highest value regarding bone % produced at3m by Allograft (54.4%), while the lowest at 5 months, by Xenografts (23.6%)

Question 2

Why haven’t you splinted the regenerated tooth?

Answer 2

Cortellini 2015 (mobility type 2/ not)

Question 3

GTR vs OFD

Answer 3

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 4

GTR vs EMD?

Answer 4

Venezia 2004literature .rev.&Meta-analysis
EMD better results than GTR (~0.5mmCAL 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 5

Overweight correlation?

Answer 5

Suvan 2015
1. Overweight & obese individuals seem to have an +risk of EP vs normal BMI
2.Overweight: OR=2.5; Obese: OR=3
3.3. Cut-off point BMI:24.3
Cavagni 2016:
1. “Cafeteria” diet causes 10% increase in A.B.Loss.
2. 2. Obesity and hyperlipidemia are potentiating factors for periodontal breakdown, especially when combined.

Question 6

Implant placement in Perio patients

Answer 6

Roccuzzo 2012performed a prospective cohort study in periodontal patients:
% of sites with bone loss ≥3mmin periodontallyhealthy/compromised andseverely compromisedpatients.
A) Sites w/ BL ≥3mm:
* PHP 5%
** Moderate PCP: 11%**
Severe PCP: 15%
B) In the percentage of sites, with bone loss ≥3 mm, a statistically significant difference between PHP and severe PCP.

Question 7

Wound healing

Kon 1969 & Susin 2015

Answer 7

Kon 196
0h: clot → 6-7d: inflammatory reaction and increase in vascularization → 12d: flap reattached to the bone and tooth → 4w: flap reattached to the tooth by dense, organized CT → 5w: mature tissue, no difference with pristine sites

Susin 2015
Hours: Hemostasis/ Clot formation
Days: Granulation tissue/ Matrix formation
Weeks: Tissue formation (repair/regenera􏰁on)
Months: Tissue remodeling/ maturation

Question 8

EMD?

Lin 2015

Answer 8

Esposito 2009 sys.rev.
Significantnt CAL gain mean =1.1mm and significant PPD reduction mean=0.9 mm

LIN 2015EMD, a mixed peptide combination derived from immature enamel of 6m-old piglets, 1st FDA approved biologic product for periodontal regeneration.

Evidence indicates that EMD for treatment of periodontal intrabony defects, when compared with OFD, EDTA, root conditioning or placebo, results in significant gain in CAL 1.3mm, reduction PPD 0.92 mm, and improvement in RX bone level 1.04 mm. However, EMD plus barrier membrane the additional benefits were limited.

Question 9

Recession GTR EMD

Answer 9

Zuhr 2014:
expected Average recession of 0.5-1.0mm post-regenerative surgery (RR=1.2) .
*involves tissue remodeling, which can result in minor
recession .
Cortellini & Tonetti 2000: Discussed expected recession following regeneration.
Recession of 0.5-1.5mm is common post-regeneration (OR=1.3).
Sculean 2005:
Minor recession of 0.5-1.0mm (RR=1.2) due to the nature of tissue healing and remodeling.

Question 10

Tapered vs parallel wall implants

Answer 10

Attieh 2018S.R&M.A Higher stability for taperedimplants atplacement & 8wbut no stat differences
At12w lower stability for tapered, but no stat differences
Taperedhadhigher torque
Tapered -> less MBL
No differencesregarding failure rate

Question 11

Osseointegration according to Berglundh 2003? 2h-12w

Answer 11

20 dogs/160 implants 8 implants /dog
Dynamic process
Establshmentphse: 2h-6w bone formation <–> resorption
Maintenancephase: 6w-12w Remodeling & function adaptation
2h: COAGULUM, mecchanical stability, chamber w/ ertyth.,neut., fibrin
4d: ANGIOGENESIS, mesenchym.cells, osteoCLASTS on bone, chamber w/ inflamm. cells n vascular structures.
1W: WOVEN BONE, w/ ost.blasts & clasts, collagen, provisional matrix, new bone in contact with SLA surface.
2W: INTENSE bone formation towards chamber, woven bone apical to imp., ost.blasts facing provisional matrix.
4W: SPONGIOUSEbone in chamber, intense remodeling in pithch regions, LAMELLAR bone formation
6W: Chamber filled w/ bone, osteons contact to imp.
8-12W: marked signs of REMODELING, bone MARROW w/ adipocytes vessels & leukocytes.

Question 12

Periodontium Vs periimplant mucosa

Answer 12

• Berglundh 91(H/x analysis), dogs: imp preseted: 3.8mm vs 3.17, //collagen fibers, LESS <Fibrob.-vessels, ,leukocytes, residual tx.
  * Berglundh 94 (vascular supply), dogs: TEETH has 1-PDL vasc. & 2-subperiosteal vssels. IMP. has ONLY subperiosteal vasc.supply, dense circular fibers, CT//imp., impaired defense (low leukocytes)
  * Abrahamsson & Soldibni 2006 (probing imp vs teeth) 4dogs: JE 1.7mm both, CT 1.2mm imp. vs 0.9mmTeeth, PTbone 1.04mm imp. vs 1.03 teeth.
• Probing acceptable D/x tool in imp. maintenance
• Berglundh 91
• Berglundh 94
• Abrahamsson 2006

Question 13

Factors that influence soft tx outcomes around implants?

Answer 13

Schwartz 2010Probing while healing: dogs, TL, freq. probing 2w-4-8-12-24w.
Frequent clinical probing at short intervals = dimensional and structuralchanges of mucosal seal
Initial healing period starts at 12w.Split formationand separation of peri-implant mucosa can facilitate bacterialcolonization
Etter 2002: first probing was after healing at 12w + used pressure-sensitive probe D0: complete separationD1: 0.5mm attachment of JE in most apical part.D5: complete attachment of JE
Abrahamsson 1997Ab.Dis./Reconnection. 5dogs, (Nobel extern.hex)T
est: JE 1.65mm, CT 0.65mm, BIC 1.5mm apical to interface (BL of 0.7mm) -> Smaller BW= 2.50mm Distance mucosal margin to interface 1.02mm => 1.5mm soft tx. recession.
Mucosal barrier disruption = epithelial proliferation to cover the wound + bone resorption to allow proper CT barrier
Multiple connections resulted in a more apically positioned CT
Berglundh 19965dogs, submerged imp. soft tx. excision.
Once imp. exposed to oral environment -> mucosal attach. foramtion to protect oss.integ.
Minimum width of periimplant tx is needed -> Bone resorption to allow space for BW to form
Wound healing included bone resorption + angular bone defect
BW around implants grows in an apical manner with bone resorption to allow proper dimension of mucosal seal
Lazzara 2006RX evaluation 13y followup
Factors C.bone around imp.:
1.3mm soft tx.
2.Position Ab. ICT(inflamm.cell.infiltrate)
3.Imp. surface topography
When IAJ (imp.Ab.Junction) positioned away (inside) from outer edge of implant (shoulder) & bone –> ICT exposure is reduced. THUSPlatform switchingrepositions Ab ICT away from crestal bone and locates ICT <90° confined area. (instead 180° like p.matching)
Rodriguez 200937 PATIENTS, P.S. imp <3mm apart.
BW around PS imp is located more coronally
PS can preserve periimplant bone
Vest.Bone resoption 0.5-0.7mm; Bone Peak rent. ~0.24nn
Schwartz 2010 (vs etter 2002)
Abrahamsson 1997
Berglundh 1996
Lazzara 2006 –> Rodriguez 2009

Question 14

Vertical soft tx. thickness & bone remodeling

Answer 14

Berglundh 19965dogs, submerged imp. soft tx. excision.
Once imp. exposed to oral environment -> mucosal attach. foramtion to protect oss.integ.
Minimum width of periimplant tx is needed -> Bone resorption to allow space for BW to form
Wound healing included bone resorption + angular bone defect
BW around implants grows in an apical manner with bone resorption to allow proper dimension of mucosal seal
Lazzara 2006RX evaluation 13y followup
Factors C.bone around imp.:
1.3mm soft tx.
2.Position Ab. ICT(inflamm.cell.infiltrate)
3.Imp. surface topography
When IAJ (imp.Ab.Junction) positioned away (inside) from outer edge of implant (shoulder) & bone –> ICT exposure is reduced. THUS** Platform switching** repositions Ab ICT away from crestal bone and locates ICT <90° confined area. (instead 180° like p.matching)
Rodriguez 200937 PATIENTS, P.S. imp <3mm apart.
BW around PS imp is located more coronally
PS can preserve periimplant bone
Vest.Bone resoption 0.5-0.7mm; Bone Peak rent. ~0.24nn
Valles 2018Syst.Rev.(14). SCL=<MBL (confirm Barros 2010), <CBL, >JE.
MICROGAP OF SCL W/ P.S. SHOWS >PERIIMPLANT MUCOSA
Berglundh 1996
Lazzara 2006
Rodriguez 2009
Valles 2018

Question 15

Submerged Vs non submerged (soft & hard tx.)?

Answer 15

Hermann 2000; Abrahamsson 1999

Question 16

BL vs TL

Answer 16

Valles 2018
Hermann 2000

Question 17

Influence of the abutment height on marginal bone level changes around two-piece dental implants

Muñoz 2022

Answer 17

Muñoz 2022
abutment: Short≤2mm vs long≥2mm
follow-up 6-36m after implant surgery. Meta-analysis revealed that long abutments ≥2mm significantly exhibited 0.3mm lower MBL changes compared with short ones at <1 year and ≥1 year

Question 18

Implant risk due to Perio-H/x?

Herrera 2023

Answer 18

Herrera 2023: EFP S3 level clinical practice guideline
patients with a history of periodontitis, dental implants undergoing regular SPIC showed an OR = 0.23 of developing peri-implantitis. (Low)

Carra 2023regular supportive peri-implant care in patients who have healthy peri-implant tissues, to reduce the risk of incident peri- implant diseases, emphasizing to the patient the importance of their adherence to SPIC visits and home care.

Question 19

Basic principles of suturing in GTR

Cortellini & Tonetti)

Answer 19

To achieve optimal postoperative results, we must consider three bioclinical principles related to suturing.
The basic principles of suturing in GTR are (Cortellini and Tonetti):
1. Maintain space.
2. Clot stability.
3. Primary closure: passive adaptation.
If you over-treat the defect, you will not meet any of the above premises.
We must learn to handle flaps both in their incision design and in their closure or suturing design.
Periodontal regeneration is very technique-sensitive and has a long learning curve.
The use of a membrane provides reassurance by offering better containment. We use a collagen membrane. It is important not to over-compact the bone substitute as it is essential to leave space for clot formation, which will then initiate true periodontal regeneration if we achieve it. Suturing and primary closure of tissues are crucial for the success of the therapy. Therefore, good flap design, good preservation of the papilla in the interdental tissues, avoiding overfilling the defect, and properly releasing the flaps to anchor them with a good suture are very important.

Question 20

Graziani 2019

CAL gain EMD vs GTR vs Memb.+bone graft

Answer 20

Graziani 2019
CAL gain of 1.27 mm with EMD vs. OFD
CAL gain of 1.43 mm with GTR vs. OFD
*CAL gain of 1.5 mm with membrane + bone graft vs. OFD
*Comparison between EMD vs GTR did not result in a statistically significant difference in terms of CAL gain.

Question 21

Sanz 2004 & Sculean 2015

Answer 21

*Histologically, periodontal regeneration is more predictable with GTR.
* The morphological characteristics and dimensions of the defects influence the clinical outcome: 3W and dehiscences > 2W or 1W / Furcation II or III / horizontal defects.
* Passive adaptation + primary closure improves results.

Question 22

What kind of new attachments can we see in perio-regeneration?

Answer 22

Nature of regeneration: Type of cell which repopulates the root surface after surgery determines the nature of the attachment that will form (Melcher 1976)
Epithelial cells = long JE.
* Karring 1985: apical migration of epithelium reduces the coronal gain of attachment, evidently by preventing PDL cells from repopulating the root surfaces
CT = root resorption:
* Nyman 1980: root portion in contact with gingival tissue demonstrated CT with fibers orientated parallel to root = gingival tissue also lacks of cells with potential to produce a new connective tissue attachment
* Karring 1984: granulation tissue derived from CT or been caused root resorption when contacting curetted root surface during healing. Rarely seen because dentogingival epithelium migrates apically to form a protective barrier against root surface
PDL = periodontal regeneration:
* Karring 1985: new attachment only on the roots with a non-impaired PDL, and never on the extracted and re-implanted roots with impaired PDL = periodontal ligament tissue contains cells with the potential to form a new CT attachment on a detached root surface
* Buser 1990: evidence that progenitor cells for new attachment formation reside on the PDL = implants placed in contact with retained root tips (whose PDL served as source of cells) showed layer of cementum with inserting collagen fibers
* Melcher 1987: progenitor cells for periodontal attachment resided in PDL and not on alveolar bone as previously assumed
Bone cells = periodontal regeneration
*Karring 1980: in coronal portion of root previously exposed to periodontitis healing resulted in ankylosis and root resorption = tissue derived from bone lacks cells with the potential to produce a new CT attachment

Question 23

Obesity & Perio?

Answer 23

• hyperinflammatory state involving adi­ pose‐tissue derived cytokines, an aberrant lipid metabolism prevalent, as well as the pathway of insulin resistance (Saito 1998; Nishimura & Murayama 2001; Akram 2016), all of which may collectively result in an accelerated breakdown of the periodontal tissues .
• positive association between obesity, defined as body mass index (BMI) ≥30kg/m2, and periodontitis
• BMI, waist‐to‐hip ratio, visceral fat, and fat‐ free mass were associated with periodontitis after adjusting for age, gender, history of diabetes, cur­ rent smoking, and socioeconomic status (Wood 2003
• Overweight & obese individuals seem to have +risk of EP in comparison with normal BMI. Obese OR=3, overweight OR=2.5. cutoff point BMI:24.3 SUVAN 2015
• Cafeteria diet increases 10% A.B.Loss & Obesity and hyperlipidemia are potentiating factors for periodontal breakdown, especially when combined. CAVAGNI 2016
• Nastimento no Sig.Diff
• Andriankaja et al. (2010) demonstrated an associa­ tion between metabolic syndrome (i.e. a combination of hypertension, impaired fasting glucose, large waist circumference, and dyslipidemia) and periodontitis
• (Morita 2011) establishing a dose–response relationship between overweight/obesity and risk for periodontitis
• However, there is inconclusive evidence on the effects of obesity on the outcomes of periodontal therapy, as evidence from longitudinal studies is sparse (Arboleda 2019)

Question 24

Diet / Nutrition & Perio?

Answer 24

Tonetti 2011 (7th EFP workshop) Diatery reccomendations:
1. Increase diatery intake of fibre, fish oil, fruits, vegetables & berries
2. Reduce refined sugar intake
3. In OBESE pt advice calorie restriction

Ramseier 2020 (promotion health lifestyle in perio pt)
Physical activity, change of diet, carb reduction and weight loss are interrelated and interdependent

Chapple 2007 High serum Vit.C =reduced Attachment Loss.
O.R. 1,3 to CAL when >Vit.C.serume[.]

Graziani 2018 2.Kiwi/d RCT
After 2months: slight but significant improvement PD, BOP & CAL

Question 25

What expect / effect subging.instrum. in CAL, BoP, PPD?

Van Der Weijden 2002

Answer 25

Deeper pockets responde better to therapy
PPD:
* ≥4mm: 0.75 reduc
* ≥7mm: 0.8 reduc
* ≥16mm: 1.4mm reduc
Subging.intrum. reduces PPD & improves CAL.