TARRSON FAMILY ENDOWED CHAIR IN PERIODONTICS

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TARRSON FAMILY ENDOWED CHAIR IN PERIODONTICS
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UCLA SCHOOL OF DENTISTRY
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Presents
Presents
Dr. E. Barrie KenneyProfessor ChairmanSection
of Periodontics
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E. Barrie Kenney B.D.Sc., D.D.S., M.S.,
F.R.A.C.D.S.
Tarrson Family Endowed Chair in Periodontics.
Professor and Chairman Division of Associated
Clinical Specialties UCLA School of Dentistry
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O V E R V I E W O F
Periodontal Regenerative Surgery
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• True regeneration can only be verified by
  removing tooth and surrounding bone for
  histologic evaluation.

Regeneration of periodontal defects involves
formation of new cementum, new attached
periodontal fibers and new bone in a region
previously destroyed by periodontal disease.
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• True regeneration can only be verified by
  removing tooth and surrounding bone for
  histologic evaluation.

• Can use most apical margin of calculus as a
  place to notch the root.

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• Any cementum with attached periodontal ligament
  fibers coronal to this notch is new attachment
  and if associated with new bone formation, then
  have most likely periodontal regeneration.

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Radiographic evidence of bone fill post surgery
is not reliable because of variation in
angulation of X-ray beam and variations in
processing film between preoperative and
postoperative radiographs.
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• Following periodontal surgery can have
  clinically decreased pocket depth, but this may
  be due to tightly adapted gingiva with a long
  junctional epithelium. Pocket depth can also be
  decreased by post surgical gingival recession.

• Clinically can evaluate Bone Regeneration by
  re-entry surgery to measure bone fill, but cannot
  ascertain if new cementum or new periodontal
  fibers have formed.

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Autogenous Bone
AUTOGRAFTS
Autogenous Bone is regarded by most clinicians as
the Gold Standard
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Osseous Coagulum
Osseous Coagulum for Bone InductionRobinson
REJ. Periodontol. 1969, 40503

• Collected from burring
• Mainly cortical bone
• Contamination (water, oil)
• Combined with osseous surgery

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Osseous Coagulum - Bone Blend Verses Flap
Curettage

• 75 sites in 28 male patients
• 37 sites in 23 patients, bone graft
• 38 sites in 13 patients, flap curettage
• Initial therapy
• Grooved splints to measure bone fill
• Re-entries at 7 to 25 weeks

• Osseous Grafts III comparison of osseous coagulum
  bone blend implants with open curettage
• Froum SJ et al
• J. Periodontol 1976, 47287

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BONE FILL (averages, in mm)
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Safescraper.3i
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Hip Marrow Graft

• Cancellous bone
• Fresh versus frozen
• Mainly case reports
• Morbidity of donor site

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Autogenous Bone

• No risk of disease or rejection
• No additional cost of material
• No commercial sponsor

• Minimal standardized data
• Data shows limited clinical results
• Based on case reports
• Similar Gold Standard in sinus lift procedures

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Decalcified Freeze- Dried Bone (D.F.D.B.)
ALLOGRAFTS
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Decalcified Freeze- Dried Bone (D.F.D.B.)
ALLOPLASTS
ALLOGRAFTS
HYDROXY APATITE FROM CORAL
OR (D.F.D.B.A.)
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DFDBA

• Variable osteogenic capacity
• Viral particles killed in processing
• Limited success in furcations
• Available in particles and putty

• Particle size 250 710 microns
• 100 ETOH (reduced lipid content)
• HCL (Decalcification)
• Washed buffered to a pH of 6.8 7
• Lyophilized
• Stoppered under vacuum

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Ability of commercial demineralized freeze-dried
bone allograft to induce new bone
formation Schwartz Z, Mellonig JT et al J.
Periodontol 1996, 9946

• 6 bone banks
• Implanted in mice
• Harvested at 4 and 8 weeks

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Intramuscular Results at 4 weeks
Ability of commercial demineralized freeze-dried
bone allograft to induce new bone
formation Schwartz Z, Mellonig JT et al J.
Periodontol 1996, 9946
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Ability of Commercial Demineralized Freeze-Dried
Bone Allograft to Induce New Bone Formation
is Dependent on Donor Age but not
Gender Schwartz Z, Somers A, Mellonig JT et
al J Periodontol 1998, 69470

• Life net bone
• Previous shown activity
• 27 batches
• Donor age 16 to 59 years
• 7 female, 20 male
• Intramuscular in mice
• 8 weeks

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Percentage of New Bone by Donor Subset
Distribution of New Bone Formation
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Comparative clinical study of porous
hydroxyapatite and decalcified freeze-dried bone
in human periodontal defects. Oreamuno S,
Lekovic C, Kenney EB, Carranza FA, Jr., Takei HH,
Prokic B J. Periodontol 1990, 61(7)399-404
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Interpore 200 versus Decalcified Freeze-Dried Bone

• Two Groups of paired defects
• at 2 clinics A B
• Mean ages
• 41.4 years, 36.2 years
• 6 month clinical
• and re-entry data

• Comparative clinical study of porous
  hydroxyapatite and decalcified freeze-dried bone
  in human periodontal defects.
• Oreamuno S, Lekovic C, Kenney EB, Carranza FA,
  Jr., Takei HH, Prokic B
• J. Periodontol 1990, 61399

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POCKET DEPTH (in mm)
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Membranes for Guided Tissue Regeneration -
Non-Resorbable- Resorbable- Periosteum

• Non-Resorbable
• Polytetrafluorothylene (PTFE)

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Resorbable Membranes

• Periosteum
• Polylactide Guidor, Atrisorb
• Polylactide glycolide Resolut, Osseoquest
• Collagen Porcine, Biogide Bovine, Biomend
• Calcium sulfate Plaster of Paris Capset

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Gore-Tex Plus Interpore versus Gore-Tex Alone

• 15 patients
• Mean age 39.4 years
• Re-entry at 6 months
• PHA plus PTFE or PTFE alone

• Treatment of Class II Furcation Defects using
  Porous Hydroxyapatite in Conjunction with a
  Polytetraflourethylene Membrane
• Lekovic V, Kenney EB, Carranza FA, Danilovic V.
• J. Periodontol. 1990, 71575

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RESULTS AT 6 MONTHS (in mm)
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Resorbable Membranes (Bio-Gide)
Bio-Gide Composite Porcine Collagen Membrane
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Collagen type 1 and 111. Top dense,cell
occlusive. Lower porous for cell attachment, clot
stabilization.
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XENOGRAFTS
Bio-Oss Protein extraction of bovine bone to
produce porous bone mineral hydroxyapatite.
Bio-Oss manufactured by deproteinizing bovine
bone with alkali at 300C for 15 hours, then
treated with solvent and sterilized.
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Small particle size 0.25 to 1.00 mm also have
large particle size 1.00 to 2.00 mm
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Ability of deproteinized cancellous bovine bone
to induce new bone formation.Schwartz Z. et
alJ. Periodontol. 2000, 711258
Analyzed 4 batches of Bio-Oss by demineralizing
them and found protein average of11 micrograms
per gram. Western blot showed this to be BMP-2
and TGFß.
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Bio-Oss Plus Bio-Gide versus Flap Debridement

• 22 paired defects
• 14 smokers 8 non-smokers
• Mean age 43
• Flap debridement as control
• 6 month clinical and re-entry data

• A controlled re-entry study on the effectiveness
  of bovine bone mineral used in combination with a
  collagen membrane of porcine origin in the
  treatment of intrabony defects in humans.
• J.Clinical Periodontol. 2000, 27889
• Camargo PM, Lekovic V, Weinlaender M, Nedic M,
  Wolinsky LE, Kenney EB.

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Bio-Oss Bio-Gide vs Flap Debridement
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Bio-Active MoleculesPlatelet-Rich Plasma
(P.R.P.)
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Platelet Rich Plasma Gel

• Platelet Rich Plasma PRP
• is obtained by sequestering and concentrating
  platelets by gradient density centrifugation

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PDGF Group of polypeptides that stimulate
protein synthesis in bone and also stimulate bone
resorption, stimulates collagen and matrix
production and angiogenesis.TGF betaß GROUP of
at least 3 polypeptides. Stimulates angiogenesis
and production of collagen, ground substance,
fibronectin. Inhibits osteoclasts and stimulates
osteoblasts to divide.
PDEGF Stimulates proliferation of keratinocytes
and fibroblastsPDAFStimulates new blood vessel
production
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PRP mainly used in sinus lifts with autogenous
bone, DFDBA or bovine bone. Case reports suggest
increased rate of bone formation. However, in
studies by FROUM et al using PRP Bio-Oss no
difference seen in bone in sinus lifts.
IGF-1Stimulates cartilage growth, bone matrix
production and replication of osteogenic stem
cellsPF-4Chemoattractant for fibroblasts and
PMNS
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• Platelet enriched plasma
• Autologous thrombin

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Platelet Rich Plasma

• 23 patients
• Interproximal defects
• Mean age 38
• 9 smokers, 14 non-smokers
• Re-entry 6 months

• Comparison between
• Bio-Oss/Bio-Gide/PRP
• and
• Bio-Oss/Bio-Gide
• Preparing for publication

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Pocket Depth (mm)
NO STATISTICALLY SIGNIFICANT DIFFERENCE
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Recombinant Human Platelet Derived Graft Factor
with DFDBA

• Periodontal Regeneration in Human Class II
  Furcations using Purified Recombinant Human
  Platelet Derived Growth Factor BB (rhPDGF-BB)
  with Bone Allograft
• Camelo M et al
• Int J Periodont Rest Dent 2003, 23213

• 3 mandibular molars, 1 maxillary
• 2 got 0.5mg/ml PDGFDFDBA
• 2 got 1.0mg/ml PDGFDFDBA
• 9-month results
• Block sections

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Results at 9 months (in mm)

• Histology shows
• regeneration coronal
• to notch
• Bone and cementum
• fill furcas
• One case had
• cementum formed over
• enamel projection

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Bio-Active MoleculesPlatelet-Derived Growth
Factor (PDGF)GEM21 S PDGF Beta Tricalcium
Phosphate (ß T.C.P.)
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USE OF T.C.P WITH 0.3 mg/ml P.D.G.F. AND
TETRACYCLINE ROOT CONDITIONING.
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6 months post surgery no re-entry data
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Eleven centers with 180 subjects 3 groups
(1) ß T.C.P. 0.3 mg/ml PDGF (2) ß T.C.P.
1.0 mg/ml PDGF (3) ß T.C.P. buffer Included
smokers up to 1 pack per day all got
tetracycline root treatment at surgery, a few
got re-entry. No pocket data available.
Platelet-Derived Growth Factor stimulates bone
fill and rate of attachment level gain results
of a large multicenter randomized clinical
trial. Nevins M, Han TJ et al. J Perio 2005
762205
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Clinical Attachment Level Gains
Bone Fill at 6 Months (from Radiographs)
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6-Month Pocket Depth Changes (from package insert)
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Bio-Active Molecules Bone Morphogenetic Proteins
(B.M.P.)
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Genetically engineered human Bone Morphogenetic
Proteins increase the amount and purity .
Osteogenin is another name for B.M. P. Most
osteogenins are bound to a carrier of bovine type
I collagen sponge or other carrier.
Bone Morphogenetic Proteins
First isolated in acid extracts of human bone by
URIST in 1965. Are part of superfamily of 43
transforming growth factor beta group. At least
16 different proteins isolated. BMP1 not part of
superfamily is a procollagen protease. BMPs
secreted by osteoblasts induce formation of
osteoprogenitor cells and stimulate new bone
formation.
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URIST at UCLA first identified BMP in 1965.This
native BMP is present in minuteamounts (1mg per
kg of bone), soneed large amounts of bone to
produce. Therefore, recombinantBMPs have been
developed.
BMPs 2, 4, 5, 6, 7 needed forregulation of
osseous tissue andfor repair. Some are more
osteoconductive, e.g., BMP2 and BMP7 more active
than BMP5.
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Recombinant BMPs require up to 10 times more
than native BMPs to give the same osteogenic
activity.
BMPs are assayed by intramuscular injection into
rodents and so initiate osteogenesis.
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• Carriers
• Demineralized Bone Matrix
• Collagen
• Resorbable polymers
• Calcium phosphate materials

BMPs need carrier to get effective bone
initiation. Ideal carrier still not found.
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--1 sinus with BMP-7 had good bone--1
sinus no bone but cyst like mass--2 sinuses had
small amount of bone insufficient for
implants--All 5 autogenous sinus grafts had
good bone
Recombined human Bone Morphogenetic Protein-7 in
maxillary sinus floor elevation surgery in 3
patients compared to autogenous bone
grafts. Van den Bergh JPA. et al J. Clinical
Periodontol. 2000, 27627
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Highest concentrations of BMP gave best clinical
results
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6 Month Clinical results using DFDBA plus Bovine
Derived Protein
25 patients with grade II furcations in lower
molars. Five with BMP Group 1
0.00 control DFDBA alone. Group 2 3.13
micrograms per mg of DFDBA Group 3 6.25
micrograms per mg of DFDBA Group 4 12.50
micrograms per mg of DFDB Group 5 25.0
micrograms per mg of DFDBA Evaluated at 6
months no re-entry
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Bio-Active MoleculesEnamel Matrix
DerivativesAmelogenin Emdogain
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• Enamel matrix derivative protein in propylene
  glycol alginate solution.
• Used in root conditioning with orthophosphoric
  acid or EDTA.

• Emdogain contains amelogenin, a matrix protein
  produced by ameloblasts and reduced enamel
  epithelium of root sheaths.

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Bio-Oss plus Emdogain and Bio-Gide composite
(collagen, polylactic acid)

• 18 paired defects
• 10 male, 8 female
• 12 smokers, 6 non-smokers
• Mean age 42 years
• 6 months clinical and re-entry data
• Control flap debridement

• Combination use of bovine porous bone, mineral
  enamel matrix proteins and an absorbable membrane
  in intrabony periodontal defects in humans
• Lekovic V., Camargo P.M., Weinlaender M.,
• Kenney E.B., Vasilic N.
• J. Periodontol 2001, 72583

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Pocket Depth (mm)
Attachment Level (mm)
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Osseous Resective Surgery
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A Longitudinal Study of Comparing Scaling
Procedures, Osseous Surgery and Modified Widman
Procedures Results After 5 YearsBecker W,
Becker BE, Caffesse R, Kerry G, Ochsenbein C,
Morrison E, Prichard J.J. Periodontol. 2001,
721675

• Private practice environment
• Experts in each technique
• No selection of best defects for each technique

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Dr. W. Becker calibrated and did all
measurements. All patient got two 1-hour units
of scaling and root planing by hygienist.
Baseline data 3 to 4 weeks post scaling.
Random assigned quadrants for root planing by Dr.
W. Becker. Osseous surgery by Dr. C.
Ochsenbein, Dr. W. Becker and Dr. B.E. Becker.
Modified Widman by Dr. G. Kerry.
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Patients seen weekly for 6 weeks post-surgery for
polish and oral hygiene instruction. Placed on
3-month recalls. Data collected yearly 4 to 6
weeks after last recall.
9 of 16 patients compliant with recalls
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Plaque Index
Pocket 7mm or Greater
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Attachment Levels 7mm or Greater
Gingival Recession in mm (Pocket 7mm or Greater)
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Periostat Plus Root Planing

• 210 Patients with 5 to 9 mm pockets and BOP
• Up to 1 hour per quadrant scaling and root
  planing with L.A.
• 9-month results
• Used 20mg Doxycycline b.i.d. or placebo
• Current smokers 25.5 placebo, 38.8 Periostat

• Subantimicrobial Dose of Doxcycline Enhances the
  Efficacy of Scaling and Root Planing in Chronic
  Periodontitis
• A Multicenter Trial
• Preshaw PM et al
• J. Periodontol 2004, 751068

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Pockets 4 to 6 mm
Pockets 7mm or more
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POCKET DEPTH (in mm)
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Bio-Oss Bio-Gide vs Flap Debridement
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THE END