Regenerative Osseous Surgery Explained

Regenerative Osseous Surgery

The following reconstructive surgical techniques have been proposed:

• Nongraft associated new attachment.
• Graft associated new attachment.
• Combination of both.

Nongraft Associated New Attachment

Various techniques of non graft associated new attachment are:

• Removal of junctional and pocket epithelium: This method include:
  • Curettage: Only 50% of junctional or pocket epithelium can be removed
  • Chemical agents: Most commonly used drugs are sodium sulfide, phenol, camphor, sodium hypochlorite and antiformin. Main disadvantage is depth of action is not controlled
  • Ultrasonic methods: Due to lack of clinician’s tactile sense while using this method it is again unsuccessful.
  • Surgical methods:
• Prevention of epithelial migration:
  • Eliminating junctional and pocket epithelium may not be sufficient because the epithelium from the excised margin may rapidly proliferate apically to become interposed between the healing connective tissue and cementum. It is done by guided tissue regeneration (GTR)Concept of GTR is based on the assumption that periodontal ligament cells have potential for regeneration of attachment apparatus to tooth.

“Comprehensive Overview Of Regenerative Osseous Surgery Procedures”

• Process of GTR offers possibility of producing new attachment in teeth with advanced periodontal destruction.
• In this technique matrix proteins and growth factors show promising results.
• This technique involves the placement of barrier membrane which bridges the space between the alveolar crest and cervical portion of tooth, thus preventing apical migration of epithelial cells from surgical flap in defective space and facilitating repopulation by cells of periodontal ligament.
• Two types of GTR membrane are used, i.e.
  • Degradable membranes: For example, collagen, polylactic acid, vicryl and Guidor membrane.
  • Nondegradable membranes: For example, Millipore, teflone membrane, Gore-tex periodontal material.
• Procedure of placement of membrane
  • Step 1: Raise a full thickness flap, extending a minimum of two teeth anteriorly and one tooth distally, to the tooth being treated.
  • Step 2: Debride the osseous defect and plane the root surface.
  • Step 3: Trim the membrane according to the size of the area being treated. The membrane should be extended approximately
  • Step 4: Suture the membrane around the tooth with a sling suture.
  • Step 5: The flap is positioned back to its original position or slightly coronal to it and is sutured using interrupted sutures. The membrane should cover completely, in case of nondegradable membrane, after 5 weeks of the operation; it should be removed with a gentle tug.

“The Role Of Bone Grafting In Regenerative Osseous Surgery”

• Clot stabilization, wound protection and space creation.
  • Successful results gained with graft materials, barrier membranes and coronally displaced flaps have been attributed to the fact that all of these protect the wound and create a space for undisturbed and stable maturation of the clot. So this suggests that preservation of the root surface, that is, a fibrin clot interface prevents apical migration of the gingival epithelium and allows for connective tissue attachment during the early wound healing period.

“Benefits Of Regenerative Osseous Surgery”

Root Biomodification

Several substances have been used to condition the root surface, for attachment of new connective tissue fiber. These include citric acid, fibronectin and tetracycline. They are used in root biomodification/root surface preparation.

Citric Acid

When used with pH 1 for 2-3 minutes on root surface, after surgical debridement it produces a surface demineralization, which intern induces cementogenesis and attachment of collagen fibers.

Action of Citric Acid

• It removes the smear layer, and may open dentinal tubules, thus allowing cementum to form with in these tubules and produces cementum pins. This could be associated with accelerated cementogenesis.
• Epithelium does not migrate apically because of the accelerated healing either by connective tissue attachment or a collagen adhesion may occur before epithelium migrates.
• Citric acid may demineralize small bits of residual calculus, disinfect the root surface and acid in removing endotoxins.

“Risk Factors For Complications In Regenerative Osseous Surgery”

Technique

• Raise full thickness flap.
• Perform thorough root planing.
• Apply cotton pellets soaked in citric acid pH 1 for 2-3 minutes.
• Remove and irrigate root surface profusely with water.
• Replace the flap and suture.

Fibronectin

• It acts as adhesive for attachment of fibroblast on root surfaces.
• It promotes connective tissue attachment and regeneration of bone.
• It prevents separation of flap and favor hemostasis.
• Prevents migration and proliferation of epithelial cells.

Tetracycline

• Remove smear layer and exposes dentinal tubules.
• Enhances attachment and spreading of fibroblasts on root surfaces.
• Decreases epithelial cell attachment.
• Reduces gingival collagenolytic activity by inhibiting neutrophil collagenases.

“Understanding The Benefits Of Regenerative Osseous Surgery”

Graft Associated New Attachment

• Autograft: Tissue transfer from one position to new position in same individual.
• Allograft: Tissue transfer between individuals of same species but with nonidentical genes.
• Xenograft: Donor of graft is from the species different from the host.
• Alloplastic graft: Graft of inert synthetic material which is sometimes known as implant material.