PERIODONTAL BONE DEFECTS: Therapeutics
- Introduction
An intraosseous lesion corresponds to a loss of the anchoring system and the alveolar bone
interdental, vestibular, lingual or palatal. Management is therefore necessary
and requires non-surgical periodontal therapy as a first line of treatment.
complementary surgical therapy is justified, but its indications are precise and
directly depend on the healing potential of the lesions.
- Factors influencing the therapeutic approach
2.1. Patient-related factors
• Age.
• Motivation and compliance.
• The quality of plate control.
• General health status and risk factors (smoking, medications, etc.).
• The financial aspect.
2.2. Factors related to periodontitis
• The clinical form.
• The extent and severity of attachment and bone loss.
2.3. Tooth-related factors.
• Accessibility.
• Strategic value, particularly prosthetic.
• Mobility.
• Occlusion.
• Coronary and radicular anatomies.
• The condition of the endodontium.
• The gingival environment (quality and quantity).
2.4. Factors related to intraosseous lesion
Regardless of the type of intraosseous lesion, the post-therapeutic tissue response is not
may not be satisfactory if the patient’s plaque control is not optimal. An index of
plate less than 20% is therefore an essential prerequisite to optimize the chances of
success of periodontal therapy. Similarly, the elimination of risk factors
modifiable improves the prognosis of these lesions and reduces the risk of recurrence of the infection
periodontal. Finally, individualized periodontal monitoring guarantees the maintenance of results in the short,
medium and long term.
- Therapeutic modalities
3.1. Non-surgical therapy
Non-surgical periodontal treatment allows for substantial improvement in clinical parameters, however, the quality of tissue response varies depending on the severity of the lesion.
Scaling and root planing (SRP) and debridement of periodontal pockets are the first step in the treatment of intraosseous lesions.
Non-surgical treatment is also indicated for large and superficial lesions but only stabilization of the lesion is possible.
For large and deep lesions, healing occurs mainly in the apical part of the defects which remain partially filled. This is why the surgical approach will be integrated into the periodontal treatment.
3.2. Surgical therapy
The goal of these techniques is to debride the lesion and modify the alveolar morphology to contain bone destruction.
3.2.1. Access flaps (simple)
Flaps are performed alone or in combination with resective or regenerative therapies. The debridement flap (sanitation) allows repair of the epithelial attachment system with new bone formation.
3.2.2. Resective techniques
These are the different procedures that allow bone resection and/or remodeling in order to correct bone lesions and recreate a physiological contour of the alveolar bone.
a). Osteotomy: this is the removal of part of the supporting bone, it is indicated in cases of:
- Bone defects with a depth of less than or equal to 3mm,
- Deep defects in a wall,
- Correct bony balconies, toris and exostoses,
- Improve irregular bone profile.
b). Osteoplasty: allows the rearrangement of the alveolar process by eliminating only the bone not involved in supporting the tooth. (See the technique in the previous course).
PERIODONTAL BONE DEFECTS: Therapeutics
Bone defect smoothed by selective grinding of bone edges
- Classic osteoplasty-osteectomy
b. Osteoplasty-osteectomy in the aesthetic sector.
- Regenerative bone surgery
Regenerative surgery was designed to optimize the migration of osteoprogenitor and mesenchymal cells from the medullary spaces and periodontal ligament within bone lesions.
They are especially indicated in the treatment of large and deep intraosseous lesions that respond partially to non-surgical treatment and access flaps.
We distinguish:
- Filling of bone lesions with autogenous bone or an osteoconductive bone substitute;
- Guided tissue regeneration (GTR), which involves the use of a non-resorbable or resorbable regeneration membrane;
- Induced tissue regeneration (ITR) via the use of enamel matrix derivatives (AMD);
- The combination of these techniques.
a). Bone filling
Bone grafts (transplant) can be performed through autograft or bone substitutes from different sources; allograft (human bone from a bank), xenograft (bone of animal origin) and alloplastic materials (synthetic materials).
This therapeutic option is particularly indicated for large and deep intraosseous defects, with three or two walls facing each other (crater).
PERIODONTAL BONE DEFECTS: Therapeutics
| Type of graft | Origin | Examples |
| Autograft | The patient himselfDonor and recipientIntra or extraoral site | Cortical bone, iliac bone, tibia bone,…..Exostoses, mental symphysis,…… |
| Allograft | The donor and the recipient are of the same species | Freeze-dried bone FDBA Fresh frozen demineralized freeze-dried bone DFDBAOs. |
| Xenograft | Bovine or porcine animal | Collagen, coral. |
| Alloplastic materials | Biocompatible synthetic artificial manufacturing materials | Ceramics, calcium phosphate, bioglass, porous or non-porous hydroxyapatite |
The different bone filling materials
- Surgical technique
Autograft in the treatment of bone lesions (Nabers and O’leary)
Initial preparation: The area is scaled and curetted, the occlusion is adjusted and the patient is taught plaque control.
Preparation of the recipient area: a mucoperiosteal flap is reclined; the granulation tissue is removed, the operator makes a series of perforations using a small round burr to facilitate the vascularization of the graft. The root surfaces are carefully scaled and polished.
Graft harvesting: Fibrous bone from the patient’s maxilla is used as a graft. The bone is obtained by trephination of the maxilla without damaging the roots. The bone can be immediately transferred to the lesion, or it can be placed in a cup containing isotonic saline.
Bone insertion: Bone particles are packed loosely into the lesion until it is filled and has a rounded surface contour.
The operator replaces and sutures the flaps, ensuring that the bone is completely covered and that a periodontal dressing is securely placed over the area.
b). Guided tissue regeneration (GTR)
The RTG technique consists of establishing a physical barrier between the root surface and the gingival tissue in order to prevent the apical migration of periodontal epithelial cells. This thus prevents the formation of a long junctional epithelium, and promotes the proliferation of desmodontal and bone cells in order to obtain new bone tissue, new cementum and new connective tissue attachment. (See previous course).
Surgical technique
- Asepsis; Anesthesia
- Incision: extend the incision over one to two teeth mesially and distally to have sufficient access and vascularization during the procedure,
- Retract the flap beyond the mucogingival junction,
- Remove the gingival sulcus epithelium present on the internal face of the flap,
- Create a partial thickness flap apically at the mucogingival junction (MGJ) to completely cover the membrane and move the flap coronally.
- Placement of the membrane on the root surface, slightly exceeding the ECJ, so that it covers the bony contours of the lesion by 2 to 3 mm apically and laterally.
- The membrane must be able to maintain sufficient space for the formation of the blood clot, so it must not be completely pressed against the root surfaces, nor be in contact with the apical edge of the flap.
- Suture of the flap: The flaps at the level of the interdental papilla covering the bone defect are sutured with simplified mattress stitches. The sector is completely closed. Be careful not to suture the membrane with the flap when suturing the latter.
- Do not place a periodontal dressing that could compress the membrane in the defect.
- Removal of the membrane four to eight weeks after the procedure.
- Separate the membrane from the inner side of the flap with a partial thickness incision.
- Retract the flap, cut the membrane sutures and carefully peel off the membrane. Be careful not to damage the newly formed tissues.
- Check that the entire membrane has been removed.
- Cover the newly formed tissues with the flap and suture with silk thread.
- Place a periodontal dressing.
c). Induced tissue regeneration (ITR)
In 1997, Heijl et al were the first to study the impact of enamel matrix derivatives (DMA) in the treatment of intraosseous lesions. These are induction factors that will allow the chemotactic attraction of pre-osteoblasts and their differentiation into mature osteoblasts; they also allow osteogenesis. This surgical approach is really interesting for several reasons:
- It generates few or no post-operative complications;
- It can be performed regardless of the periodontal morphotype (thick or thin);
- It is advantageous in the presence of multiple bone defects;
- Clinical outcomes are better when bone defects are self-supporting.
d). The association of techniques with regenerative aims
To compensate for therapeutic deficits in significant intra-osseous losses, some authors have proposed the association of regenerative techniques :
- Bone defect filling with biomaterials and RTG.
For three-wall defects; no significant difference is observed between the combined treatment (filling + membrane) or RTG alone.
For non-self-supporting single- or double-walled defects, the combination of the two treatments appears to give clinically and histologically more favorable results compared to the use of one technique alone.
- Bone defect filling with biomaterials and RTI
The aim of this association is on the one hand to avoid the collapse of the flap and on the other hand to ensure maintenance of the scar space for the ligament mesenchymal cells attracted by the DMAs.
The combination of an inorganic bovine bone substitute (Bio-Oss) with DMA (Emdogain) appears to provide the best clinical results compared to the use of Emdogain alone.
PERIODONTAL BONE DEFECTS: Therapeutics
CONCLUSION
The treatment of intraosseous lesions is a therapeutic challenge for the practitioner. The key to a
Successful periodontal treatment for intraosseous lesions lies in early diagnosis,
therapeutic planning, good oral hygiene, careful execution of
therapeutic modalities ranging from non-surgical treatment to regenerative techniques
advances. Thanks to numerous instruments, materials and techniques, we have been able over the years to
years, improve the results and sustainability of treatments.
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