Periodontal Regeneration

Regeneration• The most ideal treatment

• Attempts to recreate the tissues destroyed by periodontitis

• Cement, bone and ligament

• Reduces the risk for recession and sensitivity (could actually improve it)

• Disadvantages:

• Cost

• Difficulty

• Predictability?

Regeneration• Based on the principle of epithelial discussion

• Membrane

• Blood clot

• Allows the different other tissue producing cells to repopulate the space

• Osteoblasts

• Fibroblasts

• Cementoblasts

Regeneration• Options:

• Bone graft (autogenic, allogenic, xenogenic)

• Membrane

• Amelogenins

• PDGF

• Combination

Mrs. AC Untreated patient requiring regeneration

Chronic Perio Localized Severe

Probing: 10mmRe-eval 12 months

Bleeding: 3mm

Regenerative therapy with Demineralized Freeze-Dried Bone Allograft

18-02-2011 22-03-2013

3 3 9 3 3 3

3 3 8 3 8 3 3 3 3 3 5 3

3 2 33 3 4

GTR T C

Lasers in Periodontics

Laser

• Several lasers have been recommended, unfortunately without strong scientific evidence.

• In addition, the proposed protocols often require repeated visits and arbitrary parameters, without scientific rigor.

Periowave Diodes Er:YAG Er,Cr,YSSG (Waterlase) CO2

Different wavelengths Different interactions

Tissue Absorption

ÉmailDentine

Laser

• Photodynamic Therapy (PerioWave)

• Surgical lasers

PERIOWAVENon-thermal diode laser

PerioWave

• Photodynamic Therapy:

• Aims to neutralize or destroy pathological tissues through the use of photosensitizing chemicals that have the property of becoming toxic when activated by light

• Used in medicine in some cancer therapy

1. Scaling and root planing 2. Application of a photosensitive

solution in the pocket where it adheres to pathogenic bacteria

3. Illumination with laser, which activates the solution and kills the bacteria selectively

Periowave Mode of Action:“Photo-disinfection”

PHOTODYNAMIC THERAPY Systematic Review 2010

SRP SRP + PDT Difference

PD reduction 0.63mm 0.87mm 0.25mm

CAL gain 0.43mm 0.78mm 0.34mm

PerioWave• Disadvantages:

• Cost

• Time

• Efficiency?

• Studies fail to demonstrate a clinically and statistically significant difference in a systematic way

• However, some clinicians have managed to have a resolution of major bone defects by using it. Protocol???

Periowave And Photodynamic Therapy Conclusions

• Limited advantages

• Inconclusive scientific evidence

• Certain results can look impressive

• Difficult to reproduce

• No scientific proof of regeneration

Diode Lasers

• Many manufacturers

• Multiple wavelengths

• Easy to use

• Less expensive than other lasers

940 nm

810 nm810 nm

980 nm

Diode Lasers

• Absorbed by soft tissue and pigmented tissue

• Long and weak pulsations

• Tendency to carbonize

Diode Lasers Indications

• Frenectomy

• Biopsy

• Sulcus preparation for impression taking

• Coagulation

• Disinfection

668 Schweiz Monatsschr Zahnmed Vol. 120 8/2010

Research and Science Articles published in this section have been reviewed by three members of the Editorial Review Board

from tongue ties to hemangiomas. General anesthesia was used in 28 patients. The remaining 12 underwent laser surgery with local anesthesia. Postoperatively, the laser-treated patients were hospitalized for a period of two days or less. Overnight hospi-talization was required in patients only when warranted by preexisting medical conditions. Since then, the CO2 laser has become the most commonly used laser in oral and maxillofa-cial surgery. The development of smaller, portable office-based lasers has allowed even minor routine procedures to be treated with the laser on an out-patient basis outside of hospital op-erating rooms (Pick 1997). These changes are reflected in the present study, where no patient had to undergo general anes-thesia and no sutures were required for any of the procedures.

With a wavelength of 10.6 µm, CO2 laser energy has a high water absorption coefficient and causes vaporization of any

dicated that the two CO2 laser modes were statistically signifi-cantly superior to the diode laser mode with respect to the thermal damage zone, and that there was no statistically sig-nificant difference between the two CO2 laser groups.

At the follow-up visits two weeks and one month after laser treatment, no postoperative complications were recorded. Pain control after CO2 and diode laser surgery could be performed with the adhesive wound paste alone in all patients, without any additional systemic non-opiate analgesics (Fig. 1E, Fig. 2E, Fig. 3E).

Discussion

In an early study on the use of the CO2 laser in oral and max-illofacial surgery, Pecaro & Garehime (1983) examined the results after CO2 laser treatment of 40 intraoral lesions ranging

Fig. 3 The preoperative, postoperative, and histopathological aspects of a typi-cal fibrous hyperplasia selected for excision with the diode laser (group C). A) Preoperative aspect; B) Postoperative aspect following laser surgery; C) Ex-cised biopsy specimen before fixation in formalin; D) Histopathological aspect (hematoxylin-eosin stain; * = zone of thermal damage); E) Postoperative as-pect one month after excision.

668 Schweiz Monatsschr Zahnmed Vol. 120 8/2010

Research and Science Articles published in this section have been reviewed by three members of the Editorial Review Board

from tongue ties to hemangiomas. General anesthesia was used in 28 patients. The remaining 12 underwent laser surgery with local anesthesia. Postoperatively, the laser-treated patients were hospitalized for a period of two days or less. Overnight hospi-talization was required in patients only when warranted by preexisting medical conditions. Since then, the CO2 laser has become the most commonly used laser in oral and maxillofa-cial surgery. The development of smaller, portable office-based lasers has allowed even minor routine procedures to be treated with the laser on an out-patient basis outside of hospital op-erating rooms (Pick 1997). These changes are reflected in the present study, where no patient had to undergo general anes-thesia and no sutures were required for any of the procedures.

With a wavelength of 10.6 µm, CO2 laser energy has a high water absorption coefficient and causes vaporization of any

dicated that the two CO2 laser modes were statistically signifi-cantly superior to the diode laser mode with respect to the thermal damage zone, and that there was no statistically sig-nificant difference between the two CO2 laser groups.

At the follow-up visits two weeks and one month after laser treatment, no postoperative complications were recorded. Pain control after CO2 and diode laser surgery could be performed with the adhesive wound paste alone in all patients, without any additional systemic non-opiate analgesics (Fig. 1E, Fig. 2E, Fig. 3E).

Discussion

In an early study on the use of the CO2 laser in oral and max-illofacial surgery, Pecaro & Garehime (1983) examined the results after CO2 laser treatment of 40 intraoral lesions ranging

Fig. 3 The preoperative, postoperative, and histopathological aspects of a typi-cal fibrous hyperplasia selected for excision with the diode laser (group C). A) Preoperative aspect; B) Postoperative aspect following laser surgery; C) Ex-cised biopsy specimen before fixation in formalin; D) Histopathological aspect (hematoxylin-eosin stain; * = zone of thermal damage); E) Postoperative as-pect one month after excision.

Adjunct Use of Diode Laser with Debridement

• Systemic review Slot et al. 2014: Debridement vs Debridement + diode

• No difference in the depth reduction of the pockets and in the improvement of the level of attachment

• Slight advantage for reducing bleeding with diode

Er:YAG• Multi-use system

• Non-selective

• Can remove calculus

• Very well absorbed by water and the root

• High damage risk

Volume 31, Number 4, 2011

359

Fig 1 Patient at initial preoperative exami-nation and work-up for surgical correction of excessive display of gingival and tooth asymmetry when smiling.

Fig 2a Surgical guide allowing transfer of the proposed, more apically positioned gingival margin determined during compre-hensive diagnostic examination.

Fig 2b With the surgical guide in place, the proposed gingival margin was trans-ferred to the patient’s tissues via a surgical marking pen.

Fig 4 Following laser-mediated gingivec-tomy, bone sounding revealed the osseous crest at the newly positioned gingival margin. Osseous resection was therefore required to create space for the biologic width.

Fig 3 The quartz laser tip was 3 mm in length—the linear distance required to accommodate the elements of the patient’s biologic width.

Fig 5 Er:YAG quartz tip advanced apically 3 mm during ostectomy procedure.

© 2011 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.. NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

The International Journal of Periodontics & Restorative Dentistry

© 2011 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.. NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

Er:YAG Allongement de couronne

• Study by McGuire et Scheyer

• Flapless approach as recommended by manufacturer

The International Journal of Periodontics & Restorative Dentistry

© 2011 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.. NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

Er:YAG Comprehensive Periodontal Pocket Therapy

• Case report by Aoki

• Multiple appointments necessary

• Ablation of external epithelium to be repeated each week. # of repetitions depends on the expected probing depth reduction (1mm par week)

• No published articles

Er,Cr;YSSG

• Similar to Er:YAG

• Air and water spray to cool down tissues

• Non-selective ablation

Er,Cr;YSSG

• Protocole DPT ™ (Deep Pocket Therapy)

• Radial Firing Perio Tip™

• Similar to protocol with Er:YAG

Er,Cr;YSSG• 2 clinical studies:

• Dyer & Sung 2012: Preliminary Retrospective Clinical Study

• Significant PD reduction with minimal recession

• Kelbauskiene et al. 2011: Split-mouth study vs debridement

• Statistically significant PD reduction of 0.8mm

CO2

• Bulky and difficult to use

• Non-selective tissue ablation

• Easily damages hydroxyapatite

• Risk of bone necrosis

• Biopsy

• Frenectomie

• Surface surgery

• Gingivectomy / gingivoplasty

• Distal wedge

CO2

Nd:YAG• Wavelength of 1064nm

• Absorbed by pigments (melanin, hemoglobin, pigmented bacteria)

• Poorly absorbed by collagen and hydroxyapatite (root and enamel)

• Not absorbed by water and cell membranes

Periolase Nd:YAG

• Eliminates the pigmented bacteria (P. gingivalis)

• Disinfects the pocket and the surrounding tissues

LANAP Protocol

Surgical Objectives in Regeneration

• Eliminate sulcular epithelium

• Disinfect

• Restrict the apical migration of the junctional epithelium

• Stabilize the blood clot

Prichard 1977

Modified Minimally Invasive Surgical Technique

M-MISTMicro-surgeryBuccal flap onlyIntact interproximal tissue

M-MIST M-MIST + Emdo

CAL gain

Bone fill

Cortellini et al 2011

M-MIST + Emdo/Biooss

4,1mm77%

4,1mm71%

3,7 mm78%

LANAP: Periodontal Regeneration

Selective Disinfects Seals the pocket

Grade III mobility Pockets of 8-16 mm

4 molars - grade III furcations LANAP and extracted en-bloc after 9 months

All teeth were clinically and radiographically healthy Pocket reduction of 5.4mm Attachment gain of 3.8mm

Clinical results

Nevins 2012 - Human Histology

12 hopeless teeth

50% regeneration 10% new attachment

40% long junctional epithelium

Histological Results (9 months)

N.b.: The teeth in this study were initially considered hopeless.

Nevins 2012 - Human Histology

Patient : 57 year-old woman Medical history: Normal, non-smoker Diagnosis: Chronic Periodontitis localized severe 6 months post-op

35 36 37

Bu 2 2 2 4 2 11 4 3 4

Li 10 10 8 3 4 10 5 2 5

35 36 37

Bu 2 2 2 4 2 5 4 2 3

Li 3 2 4 3 2 5 3 2 2

Patient : 52 year old woman Medical history: Normal, non-smoker Diagnosis: Chronic Periodontitis generalized severe

9 months post-op

17 16 15 14Bu 6 3 6 8 3 5 8 6 7 7 4 6Li 7 4 6 8 3 5 10 8 6 8 3 6

17 16 15 14Bu 3 3 3 2 2 2 2 2 2 2 1 3Li 4 2 3 3 2 3 3 2 3 3 2 3

13 12 11Bu 6 3 5 8 7 5 5 3 4Li 7 5 4 8 8 5 5 3 3

13 12 11Bu 2 2 3 3 2 3 2 2 2Li 3 2 3 3 2 2 2 2 2

9 months post-op

Laser: Conclusion

• Until now, the Nd:YAG with the LANAP protocol is the only laser to have histologically demonstrated a new attachment and even regeneration

• Other lasers and protocols appear promising, but scientific evidence is still weak

• Further research is needed in this area

Maintenance Phase

Maintenance Phase● The most important factor for successful treatment as well as

long-term control of periodontal disease

● The frequency depends on:

- Control of the plaque

- Severity of disease

- Degree of inflammation (bleeding on probing, suppuration)

● In general: 3 to 4 months

Group with maintenance : 0.2 teeth lost in 6 years

Group with no maintenance:: 0.7 teeth

lost in 6 years

The Importance of the Maintenance Phase

Axelsson & Lindhe (1981)

Long-term maintenance of patients treated for advanced periodontal disease

● 61 pts, with 50% or more loss of periodontal support ● OHI, SRP, Pocket reduction surgeries, maintenance appointments

every 3-6 months for 14 years ● 92-99% of sites maintained pockets <4 mm ● Less than 1% of the sites developed PD> 6 mm ● During the 14 years, 2.3% of the teeth were lost (30/1330)

Lindhe & Nyman, 1984

Maintenance Appointment● The time allocated must be based on the needs of each patient

● Includes 5 parts (60 minutes for a regular patient):

1) Review, reassessment and diagnosis (5-10 min)

2) Motivation and re-instruction (5 min)

3) Instrumentation (30 min)

4) Treatment of re-infected sites (10 min)

5) Polishing and planning of future maintenance appointments (5 min)

Periodontal Protocol for Your Clinic

Periodontal Protocol for Your Clinic

• DIAGNOSIS!!!

• PSR III ou IV requires a periodontal evaluation

Periodontal Evaluation• Hygienist or dentist?

• Fees?

• Enough time to do it at the recall or separate periodontal assessment appointment?

• Taking the chart and X-rays

• Evaluation of risk factors

• Explanation of periodontitis

• Development of treatment plan

Periodontal Protocol for Your Clinic• Patients with pockets of 4-6 mm and horizontal bone loss can

usually be treated non-surgically

• Effective debridements completed within a reasonable period of time (2-4 weeks). Systemic antibiotics for aggressive and / or immuno-compromised patients

• Re-evaluation after 4-12 weeks

• Cases with residual pockets of ≥5mm require more attention, especially if presence of inflammation

Periodontal Protocol for your Clinic

Patients with: • Pockets of ≥7 mm • Deep furcations • Vertical defects

Surgical intervention anticipated

Management1. Personalized oral hygiene instructions

2. Debridement (2 appointments)

3. Control of risk factors

Re-evaluation after 4-12 semaines (+/- supportive periodontal maintenance)

Additional interventions

Residual pockets ≥5mm + inflammation

Maintenance

Pockets ≤ 4mm + absence of inflammation

*Nightguard, Orthodontics, Prosthodontics

Periodontal Protocol for Your Clinic• Once active treatments are completed, the patient should enter

maintenance

• Depending on the case, frequency between 3 to 6 months

• Every 3 months the first year

• In slight cases, can be reduced to every 4 months; or when PDs ≤4mm without BOP

• Do not hesitate to return to 3 months if situation worsens

• If the patient was referred, the periodontist will dictate the frequency and schedule of cleanings (alternating)

Periodontal Protocol for Your Clinic• Recurrence:

• A few pockets of 5mm :

• Reinforce oral hygiene

• Increase the frequency of recalls

• Repeat localized Sc/Rp +/- local antibiotics or Periowave?

• Re-evaluation at next recall

Periodontal Protocol for your Clinic

• Recurrence:

• Multiple pockets of 5mm :

• Reinforce oral hygiene

• Increase the frequency of recalls

• Generalized Sc/Rp +/- systemic antibiotics?

• Re-evaluation at next recall

Periodontal Protocol for your Clinic

• Recurrence:

• Negative results to previous treatments or residual pocket of ≥6 mm :

Refer the patient

THANK YOU!