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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Platelet Rich Plasma Gel

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

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Platelet rich plasma gel is an autologous
modification of fibrin glue made by mixing
platelets and fibrinogen centrifuged from whole
blood with thrombin and calcium chloride.
Increase platelet concentration in wound by more
than 300 percent.
The PRP is then mixed with calcium chloride and
bovine thrombin to form clot that binds bone
graft material. Bovine thrombin has been used in
cardiovascular surgery and there are 32 reported
cases of bleeding disorders due to cross
reactivity of bovine factor V causing antibodies
to human factor V. No cases seen in bone
grafting use of PRP. Can substitute human
recombinant thrombin or patients own thrombin
separated out in a separate protocol or extra
purified bovine thrombin.
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Preparation of Platelet Rich Plasma (P.R.P.)
Harvest System 3i System
Average Platelets in 6 ml 1.5 million 1.2 million
Time for Isolation 15 minutes 20 minutes

• Use of general purpose centrifuges
• 450 ml blood in citrate phosphate anticoagulant
  placed in centrifuge at 5,600 rpm to get buffy
  coat of platelets plus leukocytes
• Slow centrifugation of buffy coat at 2,400 rpm to
  obtain 30 ml of platelet rich plasma.
• Takes 30 minutes and should be used within 6 hours

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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 plus Bio-Oss plus Biogide
versus Platelet Rich Plasma and Bio-Oss

• 21 Paired Defects
• 6 Males, 15 Females
• 9 smokers 12 non-smokers
• Mean age 40 years
• 6 month clinical and re-entry data

• Comparison of Platelet Rich Plasma, Bovine
  Porous Bone Mineral and Guided Tissue
  Regeneration versus Platelet Rich Plasma and
  Bovine Porous Bone Mineral in the treatment of
  Intrabony defects
• a Re-entry Study
• Lekovic V, Camargo PM, Weinlaender M, Vasilic N,
  Kenney EB
• J. Periodontol 2002, 73198

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Pocket Depth (in mm)
PRPBioOss Biogide PRPBioOss
Attachment Gain (mm) 4.12 3.78
Bone Fill (mm) 4.96 4.82
Initial 6 Months
PRPBioOss Biogide 7.81 3.62
PRPBioOss 7.96 3.98
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Platelet Rich Plasma plus Bio-Oss plus Atrisorb
versus Atrisorb alone

• 18 paired defects
• 10 males 8 females
• 6 smokers 12 non-smokers
• Mean age 39 years
• 6 month clinical and re-entry data

• Platelet Rich Plasma and Bovine Porous Mineral
  combined with guided tissue regeneration in the
  treatment of intrabony defects in humans.
• Camargo PM, Lekovic V, Weinlaender M, Vasilic N,
  Madzarevic M, Kenney EB
• J Periodont. Res 2002, 37300

Atrisorb-Polylactide in n methyl 2 pyrrolidine.
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Pocket Depth (mm)
PRPBioOss Atrisorb Artisorb
Attachment Gain (mm) 4.37 2.62
Bone Fill (mm) 4.78 2.31
Initial 6 Months
PRPBioOss Atrisorb 7.87 2.89
Atrisorb 7.78 4.16
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Bio-Oss plus Bio-Gide plus Platelet Rich Plasma
versus Flap Debridement

• 28 Paired Defects
• 12 Females 16 Males
• Mean age 41.0 years
• 12 Smokers 16 Non-smokers
• Clinical and re-entry data
• at 6 months

• A Re-entry study on use of Bovine Porous bone
  mineral guided tissue regeneration and Platelet
  Rich Plasma in the treatment of intrabony defects
  in humans.
• Camargo PM, Lekovic V, Weinlaender M, Vasilic N,
  Madzarevic M, Kenney EB
• Int. J. Periodont. Rest. Dent. 2005, 2549

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Pocket Depth
Bio-Oss Bio-GidePRP Flap Curettage
Attachment Gain (mm) 4.37 2.62
Bone Fill (mm) 4.78 2.31
Initial 6 Months
Bio-Oss Bio-GidePRP 7.87 2.89
Flap Curettage 7.78 4.16
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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)
BioOss BiogidePRP BioOss Biogide
Attachment Gain (mm) 4.38 3.56
Bone Fill (mm) 4.81 3.96
Initial 6 Months
Bio-Oss Bio-GidePRP 8.19 3.31
Bio-Oss Bio-Gide 8.11 3.95
NO STATISTICALLY SIGNIFICANT DIFFERENCE
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Control PDGF
Fibroblasts 9.3 2.0 70.8 14.6
Cementoblasts 0.4 0.2 2.5 0.5
Osteoblasts 0.5 0.2 3.6 0.7
Perivascular Cells 2.7 0.6 7.2 1.3
Endothelial Cells 0.7 0.2 3.7 1.0
HIGHLY PURIFIED RECOMBINANT PLATELET DERIVED
GROWTH FACTOR
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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

Vertical probing Horizontal probing Attachment
Cases Before After Before After gain
0.5mg/ml 8 2 7 4 6
0.5mg/ml 8 3 7 3 4
1.0mg/ml 6 2 5 3 4
1.0mg/ml 5 3 6 4 1
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.
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THE END
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THE END
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TRI CALCIUM PHOSPHATE
PORES 1-500 MICRONS
PARTICLES 0.25 -1.00 MM.
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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 few re-entries done
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1 week post surgery
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6 months post surgery
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THE END
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THE END
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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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Used human BMP (osteogenin) Collaplug and DFDBA,
in humans. Took 36 block sections from 8
subjects with submerged roots and 50
non-submerged defects in 6 patients. Used
calculus as a baseline measurement of
regeneration.
Histologic comparison of Regeneration in Human
Intrabony defects when Osteogenin is combined
with Demineralized Freeze-Dried Bone Allograft
with purified bovine collagen. Bowers G. et
al J Periodontol. 1991, 62690
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50 Non-Submerged Defects
36 Submerged Defects
New Bone New Cementum New Attachment
Collaplug 0.08 0.11 0.08
Collaplug BMP 0.20 0.08 0.05
DFDBA 2.48 1.73 1.72
DFDBA BMP 2.70 2.35 2.33
New Bone New Cementum New Attachment
Collaplug 0.78 1.26 0.74
Collaplug BMP 0.70 1.20 0.67
DFDBA 1.32 1.75 1.31
DFDBA BMP 1.98 2.31 1.92
DFDBABMP significantly better than all other
groups Bowers
No significant difference between DFDBA and
DFDBABMP
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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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• 6 patients3 got BMP-7 in collagen in 4 sinus
  lifts3 got autogenous iliac bone in 5 sinus
  liftsAt 6 months took out bone cores.

A feasibility study evaluating rhBMP-2
absorbable collagen sponge for maxillary sinus
floor augmentation. Boyne P. et al Int. J.
Perio. Res. Dent. 1997, 1711
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• Got good bone in cores
• One patient had mucus retention cyst on CT at 16
  weeks
• Got mean bone height increase of 8.51 mm to 15.73
  mm
• 8 to 11 patients had sufficient bone for implant
  placement.
• 2 biopsies at 19 weeks had moderate amount of
  bone
• 10 biopsies at 24 to 27 weeks had moderate to
  large amounts of bone.

Collagen sponge bovine type 1 collagen 12
patients with sinus lifts evaluated with CT scans
at 16 weeks and bone biopsies (7 cases) at 14
weeks to 27 weeks.
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This Bovine protein extract (Neo osteo, Sulzer)
contained Bone Morphogenetic Proteins 2, 3, 4, 6,
7, 12, 13.
Bovine derived bone protein extract in the
treatment of mandibular class II
furcations. Camargo PM, Wolinsky LE, Burgess
AJ, Wagner WR, Paluk SF, Kenney EB. Compend.
Cont. Edu. Dent. 2002, 231023
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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
Control Group 1 Group 2 Group 3 Group 4 Group 5
Pocket Depth Change 1.3 1.0 1.1 1.8 1.7
Vertical Attachment Level Change 0.5 0.8 0.5 1.5 1.5
Horizontal Attachment Level Change 1.9 0.5 0.4 1.1 1.8
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Highest concentrations of BMP gave best clinical
results
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THE END