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Classic Lit Fall 2021 > Periodontal Regeneration > Flashcards

Periodontal Regeneration Flashcards

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1
Q

New attachment

A

New attachment involves the embedding of new PDL fibers into new cementum and attachment of the gingival epithelium to a tooth surface previously denuded by disease

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2
Q

Reattachment

A

Reattachment is the reunion of epithelial and connective tissue with a root surface and refers to repair in areas of the root not previously exposed to the pocket such as after surgical detachment of tissues, traumatic tears of cementum, tooth fractures

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3
Q

Bone fill

A

Does not address presence or absence of new cementum, PDL, or alveolar bone histologically!
Refers to clinical assessment (Probe resistance and radiodensity)

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4
Q

Biodegradable vs Bioresorbable vs Bioabsorbable

A

Biodegradable refers to degrading WITHOUT PROOF OF ELIMINATION

Bioresorbable refers to degradation with ELIMINATION THROUGH NATURAL PATHWAYS (metabolism)

Bioabsorbable refers to DISSOLVING in body fluids with no enzymatic degredation required

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5
Q

What is GTR?

A

a surgical procedure with the goal of gaining new bone, cementum, and PDL attachment to a periodontally diseased tooth with the use of barrier membranes.

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6
Q

Karring et al. 1980a and b

A

No barrier used - gingival contact caused resorption - No CT attachment (bone and gingiva fail to induce CT attachment)

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7
Q

What was the first GTR in human?

A

Nyman et al. 1982b

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8
Q

Nyman et al. 1982a and b

A

used Milipore filter membrane
New cementum inserted collagen fibers at apical end
CT adhesion with no new cementum at coronal

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9
Q

Gottlow et al. 1984

A

Milipore filter VS Flap alone

Milipore filter had considerably more attachment

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10
Q

What functions do the barrier membrane provide?

A

Space Maintenance
Epithelial Exclusion
Wound Stabilization

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11
Q

How many cell types are competing for the healing space in GTR?
What are they?

A 
5
Epithelial cells
Connective Tissue Fibroblasts
Alveolar bone cells
PDL cells
Cementoblasts
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12
Q

What happens to an exposed root surface when it is repopulated with different cell types?

A

Caffesse & Becker 1991

Epithelial: Long junctional epithelium
Connective tissue: root resorption
Osseous: ankylosis
PDL: regenerated attachment

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13
Q

Why is Nyman 1982 a landmark study for GTR?

A

Proof of new cementum formation with inserting collagen fibers 3mo after GTR
Showed concept of excluding soft tissue (CT and epi) to allow multipotent PDL stem cells to form new attachment

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14
Q

Wang & Boyapati 2006

A

PASS Principle for predictable GBR (GTR)

Primary wound closure
Angiogenesis
Space maintenance/creation
Stability of the wound

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15
Q

What do each principal of PASS provide?

A

Primary wound closure: facilitate tissue maturation

Angiogenesis: cells which release growth factors/cytokines/undifferentiated cells to repopulate

Space: bone graft/membranes/CAF/tenting screws - space for bone formation

Stability: necessary for wound healing/clot formation/barrier fixation

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16
Q

How many methods of regeneration are there? what are they?

A

5

Interdental denudation
Coronally Advanced Flap
Grafts
GTR (Membrane)
Biologic Agents
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17
Q

What biomaterials are used in GTR?

A

Membranes
Grafts
Biologic agents

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18
Q

What options are there for Non-Resorbable Membranes?

A 
Cellulose Ester Millipore Filter
ePTFE (Gore-Tex)
dPTFE
Titanium-reinforced ePTFE
Titanium Mesh
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19
Q

What does e/dPTFE stand for

A

Expanded/Dense Polytetrafluoroethylene

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20
Q

Pore size of Cellulose Ester Millipore Filter

A

0.22µm

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21
Q

Pore sice for ePTFE

A

0.45µm

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22
Q

Pore size for dPTFE

A

0.2µm

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23
Q

For Non-resorbable membranes - why do we get a thin layer of soft tissue on the inside of the membrane?

A

Foreign body reaction

Micro-movement induced fibrous encapsulation

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24
Q

What characteristics are membranes made based on?

A 
Biocompatibility
Maintaining Vascularity
Cell occlusion (Epi/CT)
Tissue Integration
Cell: Migration, Attachment, Proliferation, Differentiation at membrane substratum
Bacterial resistance
Space-making capability
Clinical handeling
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25
What function(s) to pours provide?
``` Tissue integration (mechanical support) Bacterial resistance (smaller pour size = less bacteria) ```
26
What classical study used an ePTFE membrane? Description/Results?
Dahlin et al. 1990 7 Monkeys - healing of Max and Mand bone defects Bio-inert ePTFE with pour size too small for Epi/CT cells (but not bacteria***) created a secluded environment for osteogenesis to take place.
27
How many borders does an ePTFE membrane have? What are they and what do they do?
2 Coronal (clot formation, collagen fiber penetration, delay epi migration) Occlusal (cell occlusion, space maintenance)
28
What is the downside of ePTFE? Citation
Larger pour size allows for bacterial invasion | Lang et al. 1994 found 30-40% membrane exposure associated bacterial infection
29
Name 2 studies that discuss impact of pore size in ePTFE | What do they say?
Larger pore size of ePTFE may allow bacteria to penetrate easier and be the reason for the greater infection rate vs dPTFE Selvig et al. 1990 Lang et al. 1994 - 30-40% exposure associated infection
30
When should a Titanium-reinforced ePTFE be used? Citation
Wide and/or Non-supportive defects Cortellini et al. 2000
31
When should Titanium Mesh be used
More for GBR
32
What studies investigated the effect of pore size on GTR?
Zellin & Lindhe 1996 | Wikesjo et al. 2003
33
What study compared pore sizes in non-resorbable membranes?
Test 3 different pore sizes 20-25µm and 100µm group had increased rate of osteogenesis vs 8µm (higher permeability and tissue integration) Zellin & Lindhe 1996
34
Wikesjo et al. 2003
Tissue occlusion does not appear to be a critical determinant, but may be a requirement for GTR
35
What options are there for resorbable membranes?
Collagen-based Polymer-based Allografts (Acellular Dermal Matrix - Amnion-Chorion)
36
What is the main difference between Cross Linked and Non-Cross Linked Collagen Membranes?
Degradation time
37
How do collagen membranes degrade?
Host Collagenases MMP1 (Fibroblasts) MMP8 (Macrophages, PMNs, Neutrophils - Inflammatory) MMP13 (Osteoclasts)
38
How are Cross Linked Collagen membranes, cross linked? What effect does it have?
Usually w/ Glutaraldehyde but can be ribose cross linked (OSSIX) Glutaraldehyde is released during the degradation process, delaying epithelial cell migration - leading to slower degradation - more time for selective cell re-population - also increased inflammatory/foreign body response though
39
How long does it take for collagen membranes to resorb? Citation
3-4weeks (Paul et al. 1992) | Longer for cross-linked
40
What are the pros and cons of cross-linked collagen membranes? Citation
Pros: Longer resorption time leading to longer time excluding epi/CT cell invasion Cons: RR of 1.43 (95% CI: 0.85-2.39) (NSSD) between the cross linked vs non-cross linked, with a marginal tendency towards higher exposure in the cross-link membrane group (Garcia et al. 2017 systematic review) The glutaraldahyde makes it too rigid! (Dr. Wang)
41
What are Polymer-based Membranes made of? (In general and specifically)
Chemically synthesized aliphatic polyesters. | Polylactide (PLA), Polyglycolide (PGA), Trimethylcarbonate
42
What is the benefit of polymer based membranes?
Better mechanical stability vs collagen
43
How are polymer based membranes reorbed? What does it result in?
Hydrolytic activity (Krebs cycle) - Acidic biproducts released - may cause fibrous layer??
44
What is the degredation rate of Polymer membranes dependent on?
pH, presence of mechanical strains, enzymes, bacterial infection, COMPOSITION
45
Which material resorbs slower for polymer membranes? (citation) how can it be modified?
PLA is more stable than PGA (Resorbs slower) (Tatakis et al. 1999) Adding crosslinked D-Lactide or Glycolide allows faster degradation
46
What membrane is PLA alone? How long do these take to resorb?
PLA alone does not appear to be available??? | Poly-D,L-Lactide: 6-12mo Poly-D,L-Lactide, Co-Glycolide: 5-6mo Jiaolong Wang et al. 2016
47
What is a CON of PLA or PLGA membranes?
Although PLA- and PLGA-based membranes are non-cytotoxic and biodegradable, the releases of oligomers and acid byproducts during degradation may trigger inflammation reactions and foreign body response in vivo (Zwahlen et al. 2009, COIR, RCT)
48
What is ADM composed of?
Human, porcine, or bovine skin
49
What can ADM be used for? citation
As an alternative to autogenous KG - Build KG around implants/teeth or for root coverage (de Andrade 2007)
50
What does lit say about ADM and infection?
May not be colonized sitnificantly by periodontopathic bacteria - even when exposed completely, still incorporated into host and heals (de Andrade 2007)
51
What is Amnion Chorion derived from?
Human placenta - inner and outer membrane (amnionic membrane - chornionic membrane)
52
CLINICAL benefits of Amnion-Chorion membranes? Citation
Lack stiffness - easily adapted to infrabony defects - no trimming/suturing needed - less surgical time/flap reflection (Szurman et al. 2006)
53
Healing benefits of Amion-Chorion membranes (citation)
Contain growth factors (PDGF-AA/VEGF (vascular endothelial...)) Could enhance wound healing and reduce bacterial contamination decreasing risk of exposure (Gulameasbasse et al 2020)
54
Compare and contrast resorbabl vs. non-resorbable membranes
NRM: Non-resorbable membrane RM: Resorbable membrane Space making: NRM better Bac resistance: NRM better Cell attachment/prolif: RM better Biologic properties: NRM: biocompatible/Bio-inert/requires removal RM: biocompatible/bio-INTERACTIVE/biodegradable Post op exposure: NRM MORE
55
What are the disadvantages of non-resorbable membranes?
2nd surgery High membrane exposure More gingival recession
56
Can resorbable or non-resorbable tolerate exposure better?
NON-RESORBABLE (tolerate better - but more often)
57
What rand of particle size should bone grafts be? (citation)
250-750microns | Kathagen et al. 1984
58
What negative effects can particle size cause? what size causes these issues?
<125microns: Foreign body reaction | >1000microns: sequestration Kathagen 1984
59
How do bone grafts help in GTR? Citaion
Maximize regenerative potential via osteoinduction, osteoconduction, and clot stabilization (Cortellini & Tonetti 2015)
60
Where can Autograft be harvested from?
``` tuberosity ramus exostoses alveolar ridge mental symphysis post-extraction sites edentulous ridge ```
61
Optimal time to take auto from extraction socket
8-12weeks (Evian et al 1982
62
What is different from tuberosity vs ramus/chin graft?
Tuberosity is highly cancellous | Chin/Ramus are monocortical
63
Buck et al. 1989/1990
Screening and freezing Allograft reduces risk of HIV transmission to 1/8million
64
What properties do allografts have? (ciotation)
Mostly osteoconductive, except DFDBA which may have osteoinductive abilities (Wang & Cooke 2005)
65
What is the difference between DFDBA/FDBA
FDBA looses cell viability and acts as a scaffold | DFDBA has exposed BMPs that can induce cell recruitment
66
How does DFDBA perform in GTR procedures?
Series of studies with DFDBA vs no graft in GTR DFDBA had new attachment apparatus, bone, and cementum (TRUE NEW ATTACHMENT) Bowers et al. 1989
67
What properties does Xenograft have?
ONLY OSTEOCONDUCTIVE serves as a scaffold
68
Which is better for GTR, Xenograft or Allograft? ()citation)
NSSD - Richardson et al. 1999
69
What are examples of Alloplast?
Hydroxyapatite, beta tricalcium phosphate, bioactive glass, some polymers
70
What are the 3 processes for sterilizing allograft?
Freezing/Ethonol bath (FDBA) Freezing/Ethanol bath/HCl (DFDBA) Solvent-dehydrated (Human HA)
71
What characteristic dos Puros have?
Osteoconductive (Human HA)
72
What are the most common biologics used today?
PRP ( Platelet rich plasma) rhPDGF (recombinant human platelet derived growth factor) EMD
73
What is PRF/PRP composed of?
PDGF, I-LGF, VEGF, TGF-b
74
What is the MOA of PRP/PRF?
Provides GFs and Platelets
75
Indications for PRF/PRP
Recession coverage/barrier membrane/Sticky Bone
76
What is the MOA of rhPDGF?
Causes Chemotaxis and Cell Proliferation
77
What are the indications for rhPDGF?
Intrabony defects Furcations Recession in combo with allograft/xenograft
78
What does rhPDGF have FDA approval for?
Intrabony defects Furcations Gingival recessions
79
What is EMD composed of
90% Amelogenin | 10% includes tuftelin, ameloblastin, enamelin and enamel proteases.
80
What is the MOA of EMD?
it induces cementogenesis
81
What are the indications for EMD?
Intrabony defects Class II Furcations Recession coverage
82
What is EMD FDA approved for?
Intrabony defects | Optimizing tissue height in esthetic zone
83
What is the MOA of BMP?
Increased proliferation/mineralization | Expression of alkaline phosphate and osteocalcin
84
Indicaitons for BMP
systemic/anatomic conditions where successful bone regen cant be achieved with conventional grafts NOT WITH DBBM
85
What is BMP FDA approved for?
Sinus augmentation | Socket preservation
86
What study is important when discussing regeneration using bone graft?
Series of histological studies by Bowers in 1989
87
Describe histological studies on regen using bone graft
``` Bowers 1989 (series) Used DFDBA vs no graft in a submerged and non-submerged environment ``` DFDBA had more new PDL, bone and cementum Regeneration only in the submerged group

Classic Lit Fall 2021 (29 decks)

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