Advanced reconstructive technologies for periodontal tissue repair

Abstract

Reconstructive therapies to promote the regeneration of lost periodontal support have been investigated through both preclinical and clinical studies. Advanced regenerative technologies using new barrier-membrane techniques, cell-growth-stimulating proteins or gene-delivery applications have entered the clinical arena. Wound-healing approaches using growth factors to target the restoration of tooth-supporting bone, periodontal ligament and cementum are shown to significantly advance the field of periodontal-regenerative medicine. Topical delivery of growth factors, such as platelet-derived growth factor, fibroblast growth factor or bone morphogenetic proteins, to periodontal wounds has demonstrated promising results. Future directions in the delivery of growth factors or other signaling models involve the development of innovative scaffolding matrices, cell therapy and gene transfer, and these issues are discussed in this paper.

Fig. 1

Periodontal wound following flap surgery: 1) gingival epithelium, 2) gingival connective tissue, 3) periodontal ligament, 4) alveolar bone and 5) cementum or dentin on the dental root surface

Fig. 2

A) Regular healing process following the periodontal flap adaptation with significant reduction of the attachment apparatus. B) In order to enable and promote the healing towards the rebuilding of cementum and periodontal ligament, the gingival epithelium must be prevented from forming a long junctional epithelium along the root surface down to the former level of the periodontal ligament (e.g. by placement of a bioresorbable membrane).

Fig. 3

Periodontal regeneration of a 3 wall infrabony defect using Emdogain A: 32 year old patient, male, non smoker with severe periodontitis. Tooth 13 shows a probing pocket depth of 10 mm disto-buccally and clinical attachment loss of 14 mm. B: Pre-treatment radiograph shows the infra-bony defect distal to the tooth 13. C: After the buccal incision of the papilla, the interdental tissue is preserved attached to the palatal flap. After the debridement of the granulation tissue and the root surface debridement, the infra-bony defect is classified and measured: the predominant component is a 7 mm deep 3-wall defect. D: 1-year after surgical intervention the distal site of the tooth #13 shows a probing pocket depth of 2 mm and clinical attachment loss of 7 mm. If compared with the initial measurements a probing pocket depth gain of 8 mm and a clinical attachment loss gain of 7 mm has been achieved. E: Radiograph 1 year post-surgery showing filling of the defect.

Fig. 3

Periodontal regeneration of a 3 wall infrabony defect using Emdogain A: 32 year old patient, male, non smoker with severe periodontitis. Tooth 13 shows a probing pocket depth of 10 mm disto-buccally and clinical attachment loss of 14 mm. B: Pre-treatment radiograph shows the infra-bony defect distal to the tooth 13. C: After the buccal incision of the papilla, the interdental tissue is preserved attached to the palatal flap. After the debridement of the granulation tissue and the root surface debridement, the infra-bony defect is classified and measured: the predominant component is a 7 mm deep 3-wall defect. D: 1-year after surgical intervention the distal site of the tooth #13 shows a probing pocket depth of 2 mm and clinical attachment loss of 7 mm. If compared with the initial measurements a probing pocket depth gain of 8 mm and a clinical attachment loss gain of 7 mm has been achieved. E: Radiograph 1 year post-surgery showing filling of the defect.

Fig. 3

Periodontal regeneration of a 3 wall infrabony defect using Emdogain A: 32 year old patient, male, non smoker with severe periodontitis. Tooth 13 shows a probing pocket depth of 10 mm disto-buccally and clinical attachment loss of 14 mm. B: Pre-treatment radiograph shows the infra-bony defect distal to the tooth 13. C: After the buccal incision of the papilla, the interdental tissue is preserved attached to the palatal flap. After the debridement of the granulation tissue and the root surface debridement, the infra-bony defect is classified and measured: the predominant component is a 7 mm deep 3-wall defect. D: 1-year after surgical intervention the distal site of the tooth #13 shows a probing pocket depth of 2 mm and clinical attachment loss of 7 mm. If compared with the initial measurements a probing pocket depth gain of 8 mm and a clinical attachment loss gain of 7 mm has been achieved. E: Radiograph 1 year post-surgery showing filling of the defect.

Fig. 3

Periodontal regeneration of a 3 wall infrabony defect using Emdogain A: 32 year old patient, male, non smoker with severe periodontitis. Tooth 13 shows a probing pocket depth of 10 mm disto-buccally and clinical attachment loss of 14 mm. B: Pre-treatment radiograph shows the infra-bony defect distal to the tooth 13. C: After the buccal incision of the papilla, the interdental tissue is preserved attached to the palatal flap. After the debridement of the granulation tissue and the root surface debridement, the infra-bony defect is classified and measured: the predominant component is a 7 mm deep 3-wall defect. D: 1-year after surgical intervention the distal site of the tooth #13 shows a probing pocket depth of 2 mm and clinical attachment loss of 7 mm. If compared with the initial measurements a probing pocket depth gain of 8 mm and a clinical attachment loss gain of 7 mm has been achieved. E: Radiograph 1 year post-surgery showing filling of the defect.

Fig. 3

Periodontal regeneration of a 3 wall infrabony defect using Emdogain A: 32 year old patient, male, non smoker with severe periodontitis. Tooth 13 shows a probing pocket depth of 10 mm disto-buccally and clinical attachment loss of 14 mm. B: Pre-treatment radiograph shows the infra-bony defect distal to the tooth 13. C: After the buccal incision of the papilla, the interdental tissue is preserved attached to the palatal flap. After the debridement of the granulation tissue and the root surface debridement, the infra-bony defect is classified and measured: the predominant component is a 7 mm deep 3-wall defect. D: 1-year after surgical intervention the distal site of the tooth #13 shows a probing pocket depth of 2 mm and clinical attachment loss of 7 mm. If compared with the initial measurements a probing pocket depth gain of 8 mm and a clinical attachment loss gain of 7 mm has been achieved. E: Radiograph 1 year post-surgery showing filling of the defect.

Fig. 4

Periodontal regeneration using platelet-derived growth factor and bone graft materials A: 27-year old patient at the reevaluation visit after the initial non-surgical therapy presented 3 sites with probing pocket depth > 6 mm, one of those distal to the tooth #44 shows a probing pocket depth of 7 mm and no gingival recession. B: The periapical radiograph shows a deep 1-wall defect distal to tooth #44 and a lesion between the teeth #45 and 46. C: The measurement of the 1-wall defect shows an infra-bony component of 6 mm D: The Grafting material (GEM 21S®) is mixed with particles of autogenous bone chips collected in the surgical area with a Rhodes instrument and with the liquid component of the GEM 21S® (platelet-derived growth factor). E: The liquid platelet-derived growth factor is placed in the defect together with the graft to rebuild the lost bone. F: A second internal mattress suture in performed with a 7- 0 Gore Tex® suture, to allow for optimal adaptation of the flap margin without the interference of the epithelium. The two internal mattress sutures are tied and the knots are performed only after a perfect free tension closure of the wound. Two additional interrupted 7-0 sutures are placed to ensure stable contact between the connective tissues of the edges of the flaps. The mesial and distal papillae are stabilized with additional simple interrupted sutures G: 9 months after surgery, the probing pocket depth is 2 mm. H: 9 months after surgery, the periapical radiograph shows a good bone fill of the 1 wall bony defect. I: 9 months after surgery, the surgical re-entry shows the new bone formation

Fig. 4

Periodontal regeneration using platelet-derived growth factor and bone graft materials A: 27-year old patient at the reevaluation visit after the initial non-surgical therapy presented 3 sites with probing pocket depth > 6 mm, one of those distal to the tooth #44 shows a probing pocket depth of 7 mm and no gingival recession. B: The periapical radiograph shows a deep 1-wall defect distal to tooth #44 and a lesion between the teeth #45 and 46. C: The measurement of the 1-wall defect shows an infra-bony component of 6 mm D: The Grafting material (GEM 21S®) is mixed with particles of autogenous bone chips collected in the surgical area with a Rhodes instrument and with the liquid component of the GEM 21S® (platelet-derived growth factor). E: The liquid platelet-derived growth factor is placed in the defect together with the graft to rebuild the lost bone. F: A second internal mattress suture in performed with a 7- 0 Gore Tex® suture, to allow for optimal adaptation of the flap margin without the interference of the epithelium. The two internal mattress sutures are tied and the knots are performed only after a perfect free tension closure of the wound. Two additional interrupted 7-0 sutures are placed to ensure stable contact between the connective tissues of the edges of the flaps. The mesial and distal papillae are stabilized with additional simple interrupted sutures G: 9 months after surgery, the probing pocket depth is 2 mm. H: 9 months after surgery, the periapical radiograph shows a good bone fill of the 1 wall bony defect. I: 9 months after surgery, the surgical re-entry shows the new bone formation

Fig. 4

Periodontal regeneration using platelet-derived growth factor and bone graft materials A: 27-year old patient at the reevaluation visit after the initial non-surgical therapy presented 3 sites with probing pocket depth > 6 mm, one of those distal to the tooth #44 shows a probing pocket depth of 7 mm and no gingival recession. B: The periapical radiograph shows a deep 1-wall defect distal to tooth #44 and a lesion between the teeth #45 and 46. C: The measurement of the 1-wall defect shows an infra-bony component of 6 mm D: The Grafting material (GEM 21S®) is mixed with particles of autogenous bone chips collected in the surgical area with a Rhodes instrument and with the liquid component of the GEM 21S® (platelet-derived growth factor). E: The liquid platelet-derived growth factor is placed in the defect together with the graft to rebuild the lost bone. F: A second internal mattress suture in performed with a 7- 0 Gore Tex® suture, to allow for optimal adaptation of the flap margin without the interference of the epithelium. The two internal mattress sutures are tied and the knots are performed only after a perfect free tension closure of the wound. Two additional interrupted 7-0 sutures are placed to ensure stable contact between the connective tissues of the edges of the flaps. The mesial and distal papillae are stabilized with additional simple interrupted sutures G: 9 months after surgery, the probing pocket depth is 2 mm. H: 9 months after surgery, the periapical radiograph shows a good bone fill of the 1 wall bony defect. I: 9 months after surgery, the surgical re-entry shows the new bone formation

Fig. 4

Periodontal regeneration using platelet-derived growth factor and bone graft materials A: 27-year old patient at the reevaluation visit after the initial non-surgical therapy presented 3 sites with probing pocket depth > 6 mm, one of those distal to the tooth #44 shows a probing pocket depth of 7 mm and no gingival recession. B: The periapical radiograph shows a deep 1-wall defect distal to tooth #44 and a lesion between the teeth #45 and 46. C: The measurement of the 1-wall defect shows an infra-bony component of 6 mm D: The Grafting material (GEM 21S®) is mixed with particles of autogenous bone chips collected in the surgical area with a Rhodes instrument and with the liquid component of the GEM 21S® (platelet-derived growth factor). E: The liquid platelet-derived growth factor is placed in the defect together with the graft to rebuild the lost bone. F: A second internal mattress suture in performed with a 7- 0 Gore Tex® suture, to allow for optimal adaptation of the flap margin without the interference of the epithelium. The two internal mattress sutures are tied and the knots are performed only after a perfect free tension closure of the wound. Two additional interrupted 7-0 sutures are placed to ensure stable contact between the connective tissues of the edges of the flaps. The mesial and distal papillae are stabilized with additional simple interrupted sutures G: 9 months after surgery, the probing pocket depth is 2 mm. H: 9 months after surgery, the periapical radiograph shows a good bone fill of the 1 wall bony defect. I: 9 months after surgery, the surgical re-entry shows the new bone formation

Fig. 4

Periodontal regeneration using platelet-derived growth factor and bone graft materials A: 27-year old patient at the reevaluation visit after the initial non-surgical therapy presented 3 sites with probing pocket depth > 6 mm, one of those distal to the tooth #44 shows a probing pocket depth of 7 mm and no gingival recession. B: The periapical radiograph shows a deep 1-wall defect distal to tooth #44 and a lesion between the teeth #45 and 46. C: The measurement of the 1-wall defect shows an infra-bony component of 6 mm D: The Grafting material (GEM 21S®) is mixed with particles of autogenous bone chips collected in the surgical area with a Rhodes instrument and with the liquid component of the GEM 21S® (platelet-derived growth factor). E: The liquid platelet-derived growth factor is placed in the defect together with the graft to rebuild the lost bone. F: A second internal mattress suture in performed with a 7- 0 Gore Tex® suture, to allow for optimal adaptation of the flap margin without the interference of the epithelium. The two internal mattress sutures are tied and the knots are performed only after a perfect free tension closure of the wound. Two additional interrupted 7-0 sutures are placed to ensure stable contact between the connective tissues of the edges of the flaps. The mesial and distal papillae are stabilized with additional simple interrupted sutures G: 9 months after surgery, the probing pocket depth is 2 mm. H: 9 months after surgery, the periapical radiograph shows a good bone fill of the 1 wall bony defect. I: 9 months after surgery, the surgical re-entry shows the new bone formation

Fig. 4

Periodontal regeneration using platelet-derived growth factor and bone graft materials A: 27-year old patient at the reevaluation visit after the initial non-surgical therapy presented 3 sites with probing pocket depth > 6 mm, one of those distal to the tooth #44 shows a probing pocket depth of 7 mm and no gingival recession. B: The periapical radiograph shows a deep 1-wall defect distal to tooth #44 and a lesion between the teeth #45 and 46. C: The measurement of the 1-wall defect shows an infra-bony component of 6 mm D: The Grafting material (GEM 21S®) is mixed with particles of autogenous bone chips collected in the surgical area with a Rhodes instrument and with the liquid component of the GEM 21S® (platelet-derived growth factor). E: The liquid platelet-derived growth factor is placed in the defect together with the graft to rebuild the lost bone. F: A second internal mattress suture in performed with a 7- 0 Gore Tex® suture, to allow for optimal adaptation of the flap margin without the interference of the epithelium. The two internal mattress sutures are tied and the knots are performed only after a perfect free tension closure of the wound. Two additional interrupted 7-0 sutures are placed to ensure stable contact between the connective tissues of the edges of the flaps. The mesial and distal papillae are stabilized with additional simple interrupted sutures G: 9 months after surgery, the probing pocket depth is 2 mm. H: 9 months after surgery, the periapical radiograph shows a good bone fill of the 1 wall bony defect. I: 9 months after surgery, the surgical re-entry shows the new bone formation

Fig. 4

Periodontal regeneration using platelet-derived growth factor and bone graft materials A: 27-year old patient at the reevaluation visit after the initial non-surgical therapy presented 3 sites with probing pocket depth > 6 mm, one of those distal to the tooth #44 shows a probing pocket depth of 7 mm and no gingival recession. B: The periapical radiograph shows a deep 1-wall defect distal to tooth #44 and a lesion between the teeth #45 and 46. C: The measurement of the 1-wall defect shows an infra-bony component of 6 mm D: The Grafting material (GEM 21S®) is mixed with particles of autogenous bone chips collected in the surgical area with a Rhodes instrument and with the liquid component of the GEM 21S® (platelet-derived growth factor). E: The liquid platelet-derived growth factor is placed in the defect together with the graft to rebuild the lost bone. F: A second internal mattress suture in performed with a 7- 0 Gore Tex® suture, to allow for optimal adaptation of the flap margin without the interference of the epithelium. The two internal mattress sutures are tied and the knots are performed only after a perfect free tension closure of the wound. Two additional interrupted 7-0 sutures are placed to ensure stable contact between the connective tissues of the edges of the flaps. The mesial and distal papillae are stabilized with additional simple interrupted sutures G: 9 months after surgery, the probing pocket depth is 2 mm. H: 9 months after surgery, the periapical radiograph shows a good bone fill of the 1 wall bony defect. I: 9 months after surgery, the surgical re-entry shows the new bone formation

Fig. 4

Periodontal regeneration using platelet-derived growth factor and bone graft materials A: 27-year old patient at the reevaluation visit after the initial non-surgical therapy presented 3 sites with probing pocket depth > 6 mm, one of those distal to the tooth #44 shows a probing pocket depth of 7 mm and no gingival recession. B: The periapical radiograph shows a deep 1-wall defect distal to tooth #44 and a lesion between the teeth #45 and 46. C: The measurement of the 1-wall defect shows an infra-bony component of 6 mm D: The Grafting material (GEM 21S®) is mixed with particles of autogenous bone chips collected in the surgical area with a Rhodes instrument and with the liquid component of the GEM 21S® (platelet-derived growth factor). E: The liquid platelet-derived growth factor is placed in the defect together with the graft to rebuild the lost bone. F: A second internal mattress suture in performed with a 7- 0 Gore Tex® suture, to allow for optimal adaptation of the flap margin without the interference of the epithelium. The two internal mattress sutures are tied and the knots are performed only after a perfect free tension closure of the wound. Two additional interrupted 7-0 sutures are placed to ensure stable contact between the connective tissues of the edges of the flaps. The mesial and distal papillae are stabilized with additional simple interrupted sutures G: 9 months after surgery, the probing pocket depth is 2 mm. H: 9 months after surgery, the periapical radiograph shows a good bone fill of the 1 wall bony defect. I: 9 months after surgery, the surgical re-entry shows the new bone formation

Fig. 4

Periodontal regeneration using platelet-derived growth factor and bone graft materials A: 27-year old patient at the reevaluation visit after the initial non-surgical therapy presented 3 sites with probing pocket depth > 6 mm, one of those distal to the tooth #44 shows a probing pocket depth of 7 mm and no gingival recession. B: The periapical radiograph shows a deep 1-wall defect distal to tooth #44 and a lesion between the teeth #45 and 46. C: The measurement of the 1-wall defect shows an infra-bony component of 6 mm D: The Grafting material (GEM 21S®) is mixed with particles of autogenous bone chips collected in the surgical area with a Rhodes instrument and with the liquid component of the GEM 21S® (platelet-derived growth factor). E: The liquid platelet-derived growth factor is placed in the defect together with the graft to rebuild the lost bone. F: A second internal mattress suture in performed with a 7- 0 Gore Tex® suture, to allow for optimal adaptation of the flap margin without the interference of the epithelium. The two internal mattress sutures are tied and the knots are performed only after a perfect free tension closure of the wound. Two additional interrupted 7-0 sutures are placed to ensure stable contact between the connective tissues of the edges of the flaps. The mesial and distal papillae are stabilized with additional simple interrupted sutures G: 9 months after surgery, the probing pocket depth is 2 mm. H: 9 months after surgery, the periapical radiograph shows a good bone fill of the 1 wall bony defect. I: 9 months after surgery, the surgical re-entry shows the new bone formation

Fig. 5

Advanced approaches for regenerating tooth-supporting structures. A) Application of a graft material (e.g. bone ceramic) and growth factor into an infra-bony defect covered by a bioresorbable membrane. B) Application of gene vectors for the transduction of growth factors producing target cells.