Year Three Periodontology#7

Elio Reyes, D.D.S.,M.S.D.

Reconstructive Periodontal Surgery Furcation Management

Chapter 67

Repair or Regeneration?RepairRepair Healing of a wound tissue that does not fully restore the Healing of a wound tissue that does not fully restore the

architecture or function of the part.architecture or function of the part. May see new gingival connective tissues and possibly new May see new gingival connective tissues and possibly new

bonebone Critical factor is how these tissues connect to the root surface. Critical factor is how these tissues connect to the root surface.

In repair there is no development of new cementum and no development of a In repair there is no development of new cementum and no development of a new PDL. It is only a partial restoration of the supporting periodontal tissuesnew PDL. It is only a partial restoration of the supporting periodontal tissues

The newly regenerated gingival connective tissues and The newly regenerated gingival connective tissues and possible new bone attach to the root via a possible new bone attach to the root via a long junctional long junctional epithelium or connective tissue adaptationepithelium or connective tissue adaptation..

Epithelium

Gingival connective tissue

Alveolar bone

Periodontal ligament

Periodontal wound healingPeriodontal wound healing

Karring T, Nyman S, Lindhe J:J Clin Periodontol 1980; 7:394Karring T, Nyman S, Lindhe J:J Clin Periodontol 1984; 11:41

Repair or Regeneration?RegenerationRegeneration is defined as a reproduction or is defined as a reproduction or

reconstitution of a lost or injured part.reconstitution of a lost or injured part. Regenerated tissues attach to the root surface in a Regenerated tissues attach to the root surface in a

similar manner to the original attachment. Thus, after similar manner to the original attachment. Thus, after healing is complete, connective tissue attaches to the healing is complete, connective tissue attaches to the root via a root via a new PDLnew PDL which engages fibers emerging from which engages fibers emerging from the root surface which is covered by the root surface which is covered by new cementumnew cementum. . When needed, new bone also forms in the appropriate When needed, new bone also forms in the appropriate location.location.

Need to remove the junctional and sulcular epithelium Need to remove the junctional and sulcular epithelium for regeneration.for regeneration.

Repair and Regeneration. The arrow indicates the most apical part of the junctional epithelium. A, Repair, healing by long junctional epithelium. Note that some bone is new but the PDL is not. B. Regeneration, new alveolar

bone, new PDL, new cementum.

AA BB

regenerationlong junctional epithelium

Consider regenerative procedure with an

intrabony defect with goodblood supply.

The probing depth is reduced by resolution of the inflammation and subsequently the probe does not penetrate as deeply. This is not new attachment

New connective tissue fibers will not attach to the root surface if epithelium is present.

PDL provides the cells needed for regeneration.

Points to remember

Probe penetrates past

the junctional epitheliumbecause of inflamed tissue

Less probepenetration withresolution of the

Inflammation.

Epithelium Control

Delay epithelial migrationDelay epithelial migrationCoronal displacement of the flapCoronal displacement of the flap

Epithelial exclusionEpithelial exclusionGuided tissue regenerationGuided tissue regeneration

Cells from the pdl have the potential for Cells from the pdl have the potential for regenerationregeneration

Figure 42-3 Sources of regenerating cells in the healing stages of a periodontal pocket. Left, Intrabony pocket. Right, After therapy the clot

formed is invaded by cells from A, the marginal epithelium; B, the gingival connective tissue; C, the bone marrow; and D, the periodontal ligament.

Epithelium Control Clot stabilizationClot stabilization

Undisturbed and stable maturation of the clot Undisturbed and stable maturation of the clot usually prevents apical migration of the epitheliumusually prevents apical migration of the epithelium

Coronally positioned flaps place the wound Coronally positioned flaps place the wound margin away from the critical healing sitemargin away from the critical healing site

Space maintenanceSpace maintenance Important in guided tissue regenerationImportant in guided tissue regeneration

Keep membrane from collapsing into the defectKeep membrane from collapsing into the defectUse titanium reinforced membranesUse titanium reinforced membranes

Tissue Healing ResponsesTissue Healing Responses

•EpitheliumEpithelium

•Connective TissueConnective Tissue

•BoneBone

•Periodontal LigamentPeriodontal Ligament

Guided Tissue Regeneration

GTR consists of placing barriers of different types to cover the GTR consists of placing barriers of different types to cover the bone and periodontal ligament, thus temporarily separating bone and periodontal ligament, thus temporarily separating

them from the gingival epithelium. them from the gingival epithelium.

Excluding the epithelium and the gingival connective tissue Excluding the epithelium and the gingival connective tissue from the root surface during the post surgical healing phase from the root surface during the post surgical healing phase

not only prevents epithelial migration into the wound but not only prevents epithelial migration into the wound but also favors repopulation of the area by cells from the also favors repopulation of the area by cells from the

periodontal ligament and the bone. periodontal ligament and the bone.

Membranes classification

ResorbableResorbableNon-resorbableNon-resorbable

Membranes classificationNon-resorbable membranesNon-resorbable membranes

First membranes used First membranes used

Require a second surgical procedure Require a second surgical procedure

Most extensive evaluated membranesMost extensive evaluated membranes

Gold standard Gold standard

Membranes classificationNon-resorbable membranesNon-resorbable membranes

Nucleopore and Millipore filtersNucleopore and Millipore filters

Ultrathin semipermeable silicon barriersUltrathin semipermeable silicon barriers

Rubber damRubber dam

ePTFEePTFE

dPTFE (non porous)dPTFE (non porous)

Salama H: Int J Periodont Restor Dent 1994;14:16

Melcher,AH: J Periodontol 1976;47: 256

Aukhil I: J Periodontol 1986; 57:727

Guided Tissue Regeneration (GTR)

Non-resorable membranesNon-resorable membranes Needs additional surgical procedure to remove membraneNeeds additional surgical procedure to remove membrane

Example: Example: Gore-TexGore-Tex®® polytetrafluoroethylenepolytetrafluoroethylene (e-PTFE)(e-PTFE)

Figure 67-9 Different shapes and sizes of expanded polytetrafluoroethylene membranes marketed by Gore-Tex (Flagstaff, Ariz).

Membrane –blocks epithelium and the gingival connective tissue;allows nutrients to pass;

titanium reinforced if needed.

Healing from bone and PDL

Gore-Tex. Transgingival microstructureGore-Tex. Transgingival microstructure

Open microstructure portionOpen microstructure portionPartially occlusive portionPartially occlusive portion

For applications involvingFor applications involving a structure, such as a tooth,a structure, such as a tooth,

that extends trough the gingivathat extends trough the gingiva into the oral environmentinto the oral environment

ePTFE

Product Information 2003: WL Gore & Associates, Inc.

ePTFE Titanium reinforced Titanium struts incorporated between two Titanium struts incorporated between two

sheets of ePTFEsheets of ePTFE Same characteristics of ePTFESame characteristics of ePTFE Added shapeability and space makingAdded shapeability and space making

Product Information 2003: WL Gore & Associates, Inc.

Guided Tissue Regeneration (GTR)

Resorbable membranesResorbable membranesBioabsorbable or biodegradableBioabsorbable or biodegradable Polylactid acid, Polyglycolic acidPolylactid acid, Polyglycolic acid

Examples:Examples: VycrilVycril® Polyglactin 910® Polyglactin 910 Resolut®, Resolut Resolut®, Resolut XT® PGA-PLA

Good handling characteristics, remains intact for 8 to 10 or 16 to 24 weeks then gradually resorbs.

Collagen membranes. Perdominantly type I collagen

Examples: Biomend, Biomend extent, Ace.

Excellent handling, biodegrades in 16 or more weeks.

Collagen membranesInitially used as gel or matrix to fill or cover periodontal Initially used as gel or matrix to fill or cover periodontal

defectsdefects

Various collagen subtypes: Various collagen subtypes: Predominantly type IPredominantly type I

Derived from different animal sources: bovine, Derived from different animal sources: bovine, porcine; tendon, dermisporcine; tendon, dermis

Wang HL:Dent Clin North Am 1998; 42:3 Laurell L, Gottlow J: Int Dent J 1998;48 Laurell L, Gottlow J: Int Dent J 1998;48

Resolut XT3-layer structure 3-layer structure

Occlusive copolimer of PLA and PGA Occlusive copolimer of PLA and PGA 85:1585:15

Porous structure with trimethylene carbonatePorous structure with trimethylene carbonate

Cross section: 2 random fiberCross section: 2 random fiber matrices on gingival and defectmatrices on gingival and defect

sides of a cell occlusive filmsides of a cell occlusive film

Surface with Trimetric patternSurface with Trimetric patternIncreases membrane flexibilityIncreases membrane flexibility

Product Information 2003: WL Gore & Associates, Inc.Product Information 2003: WL Gore & Associates, Inc.Laurell L, Gottlow J: Int Dent J 1998;48 Laurell L, Gottlow J: Int Dent J 1998;48

McClain and SchallhornInt. J. PERIO REST DENT 1993

5 Year results evaluating 76 sites in 32 patients5 Year results evaluating 76 sites in 32 patients Guided Tissue Regeneration was Guided Tissue Regeneration was

significantly enhanced by the addition of root significantly enhanced by the addition of root conditioning and grafting proceduresconditioning and grafting proceduresUsed citric acid for root conditioning and Used citric acid for root conditioning and

DFDBADFDBA Sites treated showed good long term stabilitySites treated showed good long term stability

Success of GTRMachtei et al J. Perio 1994

Mandibular class two furcationsMandibular class two furcations 30 subjects with a one year surgical re-entry30 subjects with a one year surgical re-entry

Probing depth reduction of 2.6 mmProbing depth reduction of 2.6 mm Horizontal probing attachment gain of 2.62 mmHorizontal probing attachment gain of 2.62 mm Vertical gain of 0.95 mmVertical gain of 0.95 mm

Pre-surgery SRp was not helpfulPre-surgery SRp was not helpful Better results in those subjects with greater initial Better results in those subjects with greater initial

pocket depth, good oral hygiene, minimal pocket depth, good oral hygiene, minimal inflammation and sites that did not harbor AAinflammation and sites that did not harbor AA

Root Preparation

MechanicalMechanical Hand instrumentsHand instruments Sonics and UltrasonicsSonics and Ultrasonics Finishing bursFinishing burs

ChemicalChemical Citric acidCitric acid FibronectinFibronectin Tetracycline hydrochlorideTetracycline hydrochloride EDTA 24%, ph neutral (PrefGelEDTA 24%, ph neutral (PrefGel®)®)

For very tenacious calculus or in those cases where the calculus and cementum

are indistinguishable, consider using a high-speed rotary diamond or a diamond

– studded ultrasonic scaler. Must have direct vision via flap

procedure.

During surgical root preparation, fine diamonds or finishing burs produce the

smoothest root surface followed by manual and power-driven scalers.

Preparation of the Root Surface

Citric acidCitric acidpH 1 for 2-3 minutesProduces a 4 μm (micron) deep demineralized

zone with exposed collagen fibers Eliminates endotoxins and bacteria from the Eliminates endotoxins and bacteria from the

tooth surfacetooth surface Retards epithelium from migrating over treated Retards epithelium from migrating over treated

rootsrootsRemoves smear layer and widens orifices of

dentinal tubules

Preparation of the Root Surface-2-

FibronectinFibronectin A glycoprotein to help fibroblasts attach to root A glycoprotein to help fibroblasts attach to root

surfacessurfaces Tetracycline HydrochlorideTetracycline Hydrochloride

Paste made from a tetracycline capsule. Paste made from a tetracycline capsule. In addition to the effects noted for citric acid In addition to the effects noted for citric acid

also see an anti-collagenolytic or collagen also see an anti-collagenolytic or collagen stabilizing effect plus a lingering antibacterial stabilizing effect plus a lingering antibacterial effecteffect

EDTA 24% ph neutral PrefGelEDTA 24% ph neutral PrefGel®® Ethylene diamine tetra acetic acidEthylene diamine tetra acetic acid

Manual Instrumentation Ultrasonics

Finishing Burs Chemical

Growth Factors

PDGF Platelet derived growth factorPDGF Platelet derived growth factorIGF Insulin like growth factorIGF Insulin like growth factorTGF Transforming growth factor alpha and TGF Transforming growth factor alpha and

beta beta

Tissue engineering aims to enhance bone grafts with growth factors

Growth Factors Dr. Sam Lynch SIU/SDMDr. Sam Lynch SIU/SDM

PDGF Platelet derived growth factorPDGF Platelet derived growth factorRecombinant (rhPDGF) is supplied Recombinant (rhPDGF) is supplied

with an inert filler (beta-tricalcium with an inert filler (beta-tricalcium phosphate) which is mixed before phosphate) which is mixed before insertioninsertion

Periodontal RegenerationAdjunctive Agents

EMDOGAINEMDOGAIN® Tissue Engineering. ® Tissue Engineering. An enamel matrix protein (mainly amelogenin) derived from An enamel matrix protein (mainly amelogenin) derived from

developing tooth buds of fetal pigs (developing tooth buds of fetal pigs (porcine)porcine).. Accelerate the growth of the pluripotential stem cells from Accelerate the growth of the pluripotential stem cells from

the PDL. The primitive cells from the PDL win the race to the PDL. The primitive cells from the PDL win the race to close the wound with new cementum, PDL and bone close the wound with new cementum, PDL and bone rather than epithelium.rather than epithelium.

Packaged in a syringe as a viscous gel that is applied to Packaged in a syringe as a viscous gel that is applied to the root surface.the root surface.

Need to completely control bleeding before applying Need to completely control bleeding before applying this productthis product

J.Perio 2000: Emdogain® produces a positive effect on J.Perio 2000: Emdogain® produces a positive effect on the osteoblastthe osteoblast

Platelet Rich Plasma (PRP)

Developed from patient’s blood with a cell separatorDeveloped from patient’s blood with a cell separator Centrifugation of 55 ml of whole blood results in Centrifugation of 55 ml of whole blood results in

approximately 10 ml of PRP which when mixed with approximately 10 ml of PRP which when mixed with thrombin and calcium chloride results in the thrombin and calcium chloride results in the degranulation of platelets and the subsequent degranulation of platelets and the subsequent release of growth factorsrelease of growth factors

Growth factors include PDGF TGFGrowth factors include PDGF TGFββ etc etc PRPPRP stimulates both hard and soft tissue maturation stimulates both hard and soft tissue maturation

and promotes healingand promotes healing

The ideal bone graft material should

Be biocompatibleBe biocompatible Completely biodegradableCompletely biodegradable Osteoconductive, osteoinductive, Osteoconductive, osteoinductive, osteogenic InexpensiveInexpensive Easy to handleEasy to handle Able to support the defect area until bone Able to support the defect area until bone

growth is completegrowth is complete

Types of grafting materials

Origin:Origin:

Autogenous: Autogenous: AutograftAutograft Human Tissue: Human Tissue: AllograftAllograft Animal: Animal: XenograftXenograft Synthetic: Synthetic: AlloplastAlloplast

Bone GraftsAutografts

Intraoral sitesIntraoral sites Osseous coagulumOsseous coagulum

Obtained by using rotary instruments on intraoral bone Obtained by using rotary instruments on intraoral bone at the surgical siteat the surgical site

Bone blendBone blend Cortical or cancellous intraoral bone that is obtained Cortical or cancellous intraoral bone that is obtained

with a trephine, chisel or rongeur. It is placed in an with a trephine, chisel or rongeur. It is placed in an amalgam capsule and triturated into particle size in the amalgam capsule and triturated into particle size in the range of 100 to 200 microns.range of 100 to 200 microns.

Cancellous Bone Marrow. Maxillary tuberosity, healing Cancellous Bone Marrow. Maxillary tuberosity, healing sockets (8 to 12 weeks) edentulous areas.sockets (8 to 12 weeks) edentulous areas.

Bone swagingBone swaging

Bone Swaging

Bone GraftsAutografts

Extraoral sitesExtraoral sitesIliac boneIliac bone

Root resorptionRoot resorptionNot practical to useNot practical to use

Allografts Graft between genetically dissimilar members

of the same species Freeze-Dried BoneFreeze-Dried Bone

Particle size 250 to 750 Particle size 250 to 750 μμmm Mineralized or DemineralizedMineralized or Demineralized

Hydrochloric acid demineralization exposes Hydrochloric acid demineralization exposes the bone inductive proteins, collectively called the bone inductive proteins, collectively called bone morphogenic proteins (bone morphogenic proteins (BMPBMP). ). For periodontal defects For periodontal defects DDFDBA is utilized FDBA is utilized

because it is because it is osteoinductiveosteoinductive. . For ridge augmentation or extraction site For ridge augmentation or extraction site

fill, the bone is not decalcified (fill, the bone is not decalcified (FFDBA) DBA) resulting in a product that better retains its resulting in a product that better retains its form form (osteoconductive(osteoconductive).).

Bone Grafts Terminology

OsteoconductionOsteoconduction.. A physical effect by which A physical effect by which the matrix of the graft forms a scaffold that the matrix of the graft forms a scaffold that favors outside cells to penetrate the graft and favors outside cells to penetrate the graft and form new bone. form new bone.

Osteoinduction.Osteoinduction. A chemical process by which A chemical process by which molecules contained in the graft (bone molecules contained in the graft (bone morphogenic protein) convert the neighboring morphogenic protein) convert the neighboring cells into osteoblasts, which in turn form bone. cells into osteoblasts, which in turn form bone.

Allografts (continued)

Freeze-Dried Bone…Freeze-Dried Bone… Ability to induce bone formation may vary with processingAbility to induce bone formation may vary with processing

Age of donor may play a factorAge of donor may play a factor BMP varies from bone to bone bank.BMP varies from bone to bone bank.

Osteogenin or bone morphogenic protein 3 (BMP3) Osteogenin or bone morphogenic protein 3 (BMP3) appears to enhance osseous regeneration and is appears to enhance osseous regeneration and is added to some bone grafting products.added to some bone grafting products.

AlloGroAlloGro®. Donor tissue material bioassayed for ®. Donor tissue material bioassayed for osteoinductive activity.osteoinductive activity.

Inactive DFDBA can be made more effective by Inactive DFDBA can be made more effective by adding recombinant human bone morphogenic proteinadding recombinant human bone morphogenic protein

See better results when DFDBA is combined with See better results when DFDBA is combined with autogenous boneautogenous bone

Probability that DFDBA might contain HIV following Probability that DFDBA might contain HIV following appropriate screening and processing procedures has appropriate screening and processing procedures has been calculated at 1 in 8 million.been calculated at 1 in 8 million.

XenograftsGraft obtained from a member of one species and transplanted to a

member of another species.

Most common xenograft used today is organic bovine Most common xenograft used today is organic bovine bone.bone.

PepGen P-15PepGen P-15®® Combination of a cell-binding peptide (p-15) with Combination of a cell-binding peptide (p-15) with

anorganic anorganic bovinebovine-derived hydroxyapatite bone matrix.-derived hydroxyapatite bone matrix. P-15 is a synthetic clone of the 15 amino acid sequence P-15 is a synthetic clone of the 15 amino acid sequence

of Type 1 collagen that is uniquely involved in the of Type 1 collagen that is uniquely involved in the binding of cells, particularly fibroblasts and osteoblasts.binding of cells, particularly fibroblasts and osteoblasts.

PepGen P-15 ParticulatePepGen P-15 Particulate PepGen P-15 Putty PepGen P-15 Putty PepGen P Flow (syringe)PepGen P Flow (syringe)

AlloplastsSynthetic grafting materials

Not a reliable substitute for autografts or allografts.Not a reliable substitute for autografts or allografts. Usually heals by fibrous encapsulation.Usually heals by fibrous encapsulation. Convenient, no significant osteoinductive capacity. Convenient, no significant osteoinductive capacity.

Examples:Examples: Calcium Sulfate. Plaster of ParisCalcium Sulfate. Plaster of Paris

CapsetCapset®® Plastic MaterialsPlastic Materials

HTR® (hard tissue replacement)HTR® (hard tissue replacement)Calcium coated polymer of Poly-methyl Calcium coated polymer of Poly-methyl

methacrylate and hydroxy ethyl methacrylatemethacrylate and hydroxy ethyl methacrylate Calcium Phosphate: Hidroxyapatite, Calcium Phosphate: Hidroxyapatite, ββTCPTCP Bioactive Glass: PerioglassBioactive Glass: Perioglass

Calcium sulfate as a bone graft Oldest bone graft material. Not expensive, easily stored and Oldest bone graft material. Not expensive, easily stored and

used.used. Properties of calcium sulfateProperties of calcium sulfate

An effective barrier membraneAn effective barrier membrane Maintains space for osteogenesisMaintains space for osteogenesis

Has angiogenic propertiesHas angiogenic properties Has a hemostatic functionHas a hemostatic function Can deliver growth factorsCan deliver growth factors Can be used in combination with other bone graft Can be used in combination with other bone graft

materialsmaterials Often mixed with DFDBAOften mixed with DFDBA

Is osteoconductiveIs osteoconductive Commercial brand is CAPSETCommercial brand is CAPSET® -- medical grade calcium ® -- medical grade calcium

sulfatesulfate

Time releaseTime release calcium sulfate undergoes controlled and uniform calcium sulfate undergoes controlled and uniform degradation over a period of 16 weeks. degradation over a period of 16 weeks. BoneGenBoneGen®®

Alloplasts-2-

Calcium PhosphateCalcium Phosphate Hydroxyapatite (HA)Hydroxyapatite (HA) Ceramic nonporous Ceramic nonporous

Examples: CalcititeExamples: Calcitite® Osteogen®® Osteogen® Generally nonbioresorbableGenerally nonbioresorbable

Tricalcium phosphate (TCP)Tricalcium phosphate (TCP) Ceramic Ceramic nonporousnonporous

Examples: Synthograft® and Peri-OSS®, Examples: Synthograft® and Peri-OSS®, Carrier of Gem21®Carrier of Gem21®

Partially bioresorbablePartially bioresorbable Porous HAPorous HA

Example: Interpore®Example: Interpore®

Alloplasts-3-

Bioactive Ceramic GlassBioactive Ceramic Glass Example: (PerioGlassExample: (PerioGlass®)®)

Silicon dioxide 45%; sodium oxide 24.5%; Silicon dioxide 45%; sodium oxide 24.5%; calcium oxide 24.5%; phosphorus calcium oxide 24.5%; phosphorus pentoxdepentoxde

When in contact with tissues attracts When in contact with tissues attracts osteoblastsosteoblasts

Non resorable?Non resorable?

Bone Grafts

Evidence indicates that significant bone fill beyond Evidence indicates that significant bone fill beyond that of debridement controls can be expected that of debridement controls can be expected following the use of bone grafts.following the use of bone grafts.

Mean defect fill averages approximately 60 to 65% Mean defect fill averages approximately 60 to 65% in a number of studies.in a number of studies.

Histologic evidence indicates some regeneration Histologic evidence indicates some regeneration occurs after the use of autogenous grafts, DFDBA, occurs after the use of autogenous grafts, DFDBA, and Xenografts. and Xenografts.

No confirmed regeneration using non-bone No confirmed regeneration using non-bone productsproducts

Bone Grafts

New bone formation starts at 7 daysNew bone formation starts at 7 days Cementogenesis at 21 daysCementogenesis at 21 days New periodontal ligament at 3 monthsNew periodontal ligament at 3 months Radiographic evidence of increasing bone Radiographic evidence of increasing bone

density often not seen until 6 monthsdensity often not seen until 6 months Maturation of grafted material may take up to Maturation of grafted material may take up to

2 years2 years

Treatment of Infrabony Defectsafter Edward S. Cohen -1

1. Full thickness mucoperiosteal flap using 1. Full thickness mucoperiosteal flap using sulcular incisions.sulcular incisions.Conservation of interproximal tissue to Conservation of interproximal tissue to

achieve primary closure.achieve primary closure.Flap extended at least one tooth mesial Flap extended at least one tooth mesial

and distal to the defect.and distal to the defect.

Treatment of Infrabony Defectsafter Edward S. Cohen -2

2. Removal of plaque, calculus, softened 2. Removal of plaque, calculus, softened cementum, and the junctional epithelium from cementum, and the junctional epithelium from the root surface.the root surface.Ultrasonics, hand instruments, finishing Ultrasonics, hand instruments, finishing

burs, smooth diamond stones are utilized.burs, smooth diamond stones are utilized.

Treatment of Infrabony Defectsafter Edward S. Cohen -3

3. Removal of all granulation tissue and 3. Removal of all granulation tissue and residual fibers attached to the bone.residual fibers attached to the bone. Fibers must be removed to open the marrow Fibers must be removed to open the marrow

spaces and permit intimate contact between graft spaces and permit intimate contact between graft material and bone.material and bone.

Use large curettes against the bony surface.Use large curettes against the bony surface. Missed any infrabony defects? Look for bleeding.Missed any infrabony defects? Look for bleeding.

Treatment of Infrabony Defectsafter Edward S. Cohen -4

4. Chemical root treatment?4. Chemical root treatment? Citric acid, tetracycline, PrefGelCitric acid, tetracycline, PrefGel®®..

5. Decortification5. Decortification Small holes made in bone using curette or small Small holes made in bone using curette or small

round bur.round bur. Permits a rapid proliferation of granulation tissue Permits a rapid proliferation of granulation tissue

with undifferentiated mesenchymal cells thus see a with undifferentiated mesenchymal cells thus see a more rapid regeneration of bone and anastomosis more rapid regeneration of bone and anastomosis of graft and bone.of graft and bone.

Treatment of Infrabony Defectsafter Edward S. Cohen -5

6. Scrape the PDL with the tip of an explorer to 6. Scrape the PDL with the tip of an explorer to promote bleeding and stimulate cell proliferation.promote bleeding and stimulate cell proliferation.

7. Placement of the graft material and/or barrier 7. Placement of the graft material and/or barrier membrane.membrane.

8. Flaps are sutured for primary closure and coronal 8. Flaps are sutured for primary closure and coronal positioning.positioning.

9. Postoperatively9. Postoperatively Antibiotics in most cases. Analgesics. Chlorhexidine. Ice. Antibiotics in most cases. Analgesics. Chlorhexidine. Ice.

Recall q. 2 weeks, then monthly.Recall q. 2 weeks, then monthly.

Six Years Later

Furcation Involvement

and Treatment.

Treatment of Furcation Involvement

Vertical / Horizontal componentVertical / Horizontal component ConcernsConcerns

Root trunkRoot trunk ConcavitiesConcavities Degree of root separationDegree of root separation Enamel projectionsEnamel projections CariesCaries

OcclusionOcclusion

Figure 68-1 Glickman's classification of furcation involvement. A, Grade I furcation involvement. Although a space is visible at the entrance to the furcation, no horizontal component of the furcation is evident on probing. B, Grade II furcation in a dried skull. Note both the horizontal and the vertical component of this cul-de-sac. C, Grade III furcations on maxillary molars. Probing confirms that the buccal furcation connects with the distal furcation of both these molars, yet the furcation is filled with

soft tissue. D, Grade IV furcation. The soft tissues have receded sufficiently to allow direct vision into the furcation of this maxillary molar.

Different anatomic features that may be important in prognosis and treatment of furcation involvement. A, Widely separated roots. B, Roots

are separated but close. C, Fused roots separated only in their apical portion. D, Presence of enamel projection that may be conducive to early

furcation involvement.

It is the horizontal component that distinguishes furcation involvement. >3mm horizontal is a class two Hamp furcation involvement

Treatment options with furcation invasion

Grade one furcation invasionGrade one furcation invasion Resolve the pocketResolve the pocket Odontoplasty if narrow and inaccessibleOdontoplasty if narrow and inaccessible Remove enamel projection if presentRemove enamel projection if present

Grade two furcation invasionGrade two furcation invasion Regenerative procedures especially in mandibular molarsRegenerative procedures especially in mandibular molars

Grade three furcation invasionGrade three furcation invasion Open furcation for patient access (mandibular)Open furcation for patient access (mandibular) Root removalRoot removal ExtractionExtraction Maintain in a compromised stateMaintain in a compromised state

Treatment options with furcation invasion

Grade one furcation invasionGrade one furcation invasion Resolve the pocketResolve the pocket Odontoplasty in some casesOdontoplasty in some cases

Grade two furcation invasionGrade two furcation invasion Regenerative procedures especially in mandibular molarsRegenerative procedures especially in mandibular molars Tooth with a class two furcation has a guarded prognosis not a Tooth with a class two furcation has a guarded prognosis not a

poor prognosispoor prognosis Grade three furcation invasionGrade three furcation invasion

Open furcation for patient access (mandibular)Open furcation for patient access (mandibular) Root removalRoot removal ExtractionExtraction Maintain in a compromised stateMaintain in a compromised state

Treatment options with furcation invasion

Grade one furcation invasionGrade one furcation invasion Resolve the pocketResolve the pocket Odontoplasty in some casesOdontoplasty in some cases

Grade two furcation invasionGrade two furcation invasion Regenerative procedures especially in mandibular molarsRegenerative procedures especially in mandibular molars

Grade three furcation invasionGrade three furcation invasion Open furcation for patient access (mandibular)Open furcation for patient access (mandibular)

Sometimes called a tunnel procedureSometimes called a tunnel procedure Root removalRoot removal Extraction Implant? Extraction Implant? Maintain in a compromised stateMaintain in a compromised state