REGENERATION

Restoration of structure and function is accomplished by "regeneration"

while replacement with simpler nonfunctional tissues is "repair.“

Repair is the replacement of dead cells with fibrous connective

tissue cells and fibers; depending on the cells affected, function
is often not restored.

• Factors Governing Regeneration

• Type of destroyed cells.
• Condition of the stroma.
• Number of remaining cells
1- Type of Cell Destroyed
“Labile cells" continually divide; they will regenerate.
Covering cells of the skin and gastrointestinal tract (oral mucosa) as
well as bone marrow cells .

"Stable cells" may divide; they may regenerate.

Parenchymal cells of the liver as well as many connective tissue
cells

"Permanent cells" cannot divide; they cannot regenerate.

Skeletal muscle cells, cardiac muscle cells, and nervous system
neurons

2 - Condition of the stroma.

The stroma of an organ is its supporting and nourishing component. It is

generally composed of fibrous connective tissue through which blood
vessels and nerves pass.

The stroma provides a framework or scaffolding upon which parenchymal

cells are attached. It is composed of collagen and reticular fibrils

Regeneration will be hindered if the stroma is destroyed. 3- Number

of remaining cells

Because regeneration depends on mitosis of nearby cells, a critical mass

of remaining cells should be present.

3- Number of remaining cells

Because regeneration depends on mitosis of nearby cells, a critical mass

of remaining cells should be present.

Wound Healing

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There are Four basic steps in repair of a wound

Clot formation

Inflammation

Proliferation “Epithelialization, Granulation ,Organization

Maturation ,Cicatrization

Clot is composed of a protein known as "fibrin

Fibrin forms a protein meshwork that serves to hold the wound together,
to prevent foreign materials from entering, and to form a scaffold into
which reparative tissue can penetrate.

Another protein, “Fibronectin" also appears in the early stages of wound

healing. This substance is derived from blood plasma

During the first several hours, a mild acute inflammatory reaction

appears.

Chemical mediators released from cells damaged during the incision

initiate the inflammatory reaction. The reaction is a mild one

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Platelets, the first response cell, release multiple cytokines including;

• Insulin-like growth factor-I (IGF-I),

• Platelet-derived growth factor-AB (PDGF-AB), PDGF-BB,

• Vascular endothelial growth factor (VEGF),

• Transforming growth factor-beta1 (TGF-beta1),

• Epidermal growth factor (EGF) .

Fibronectin, fibrinogen, histamine serotonin, and vonWillebrandactor

Platelet degranulation also activates the complement cascade, specifically

C5a, which is a potent chemoattractant for neutrophils

Neutrophil

• The second response cell to migrate to the wound

• Responsible for debris scavenging

• Complement-mediated opsonization of bacteria.

• Bacteria destruction via oxidative burst mechanisms (i.e.,

superoxide and hydrogen peroxide formation).

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• The neutrophils kill bacteria and decontaminate the wound from
foreign debris (microphagocyte
• Elaborate IL-1
• Macrophages
• The next cells present in the wound are the macrophages
(monocytes).
• Macrophages secrete numerous enzymes as Collagenases, which
• debride the wound
• Interleukins and tumor necrosis factor (TNF), which stimulate
fibroblasts (produce collagen) and promote angiogenesis.
•
Growth factors
Cytokine Cell of Origin Function

PDGF Platelets Cell chemotaxis

Macrophages Mitogenic for fibroblasts
Endothelial cells Stimulates angiogenesis
Stimulates wound
contraction

TGF-alpha Macrophages Mitogenic for

T lymphocytes keratinocytes and
Keratinocytes fibroblasts
Stimulates keratinocyte
migration

TGF-beta Platelets Cell chemotaxis

T lymphocytes stimulates angiogenesis
Macrophages and fibroplasia
Endothelial cells
Keratinocytes

EGF Platelets Mitogenic for

Macrophages keratinocytes and
fibroblasts
Stimulates keratinocyte
migration

Fibroblast growth Macrophages Chemotactic and

factor Mast cells mitogenic for fibroblasts
T lymphocytes and keratinocytes
Endothelial Ce Stimulates angiogenesis

Keratinocyte growth Fibroblasts Stimulates keratinocyte

factor migration, differentiation,
and proliferation

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Growth factors normally are detectable only at a very low
concentrations. They are deposited in response to specific stimuli.
These stimuli can be major or minor wound healing events such as
clot formation, cell damage, neovascularization, and the presence of
inflammatory mediators.

Interleukin (IL)–1, Macrophages IL-1 - Induces fever

IL-2, IL-6, and IL-8 Mast cells and
Keratinocytes adrenocorticotropic
Lymphocytes hormone release,
enhances TNF-
alpha and
interferon (INF)–
gamma, activates
granulocytes and
endothelial cells,
and stimulates
hematopoiesis
IL-2 - Activates
macrophages, T
cells, natural killer
cells, and
lymphokine-
activated killer
cells; stimulates
differentiation of
activated B cells;
stimulates
proliferation of
activated B and T
cells; and induces
fever
IL-6 - Induces fever
and enhances
release of acute-
phase reactants by
the liver
IL-8 - Enhances
neutrophil
adherence,
chemotaxis, and
granule release

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INFs (IFN-alpha, Lymphocytes Activate
-beta, and -delta) Fibroblasts macrophages
Inhibit fibroblast
proliferation

Angiogenesis, is stimulated by TNF-alpha, the new capillaries deliver

nutrients to the wound and help maintain the granulation tissue
bed.

- The final part of the proliferative phase is granulation tissue

formation. Fibroblasts differentiate and produce ground substance
and then collagen. The ground substance is deposited into the
wound bed; collagen is then deposited as the wound undergoes the
final phase of repair.

4-- The final phase of wound healing is the maturational phase.

Collagen deposition continues for a prolonged period, but the net

increase in collagen deposition plateaus after 21 days.

The wound undergoes contraction, ultimately resulting in a smaller

amount of apparent scar tissue.

Healing of Periodontal Wound

The healing of periodontal wounds following flap surgery is a
more complex process than that which takes place in a skin injury.

The flap of soft tissue is located over a hard tissue, the root, with an
avascular surface, sometimes contaminated with bacteria and toxic
materials.

The most common healing of a periodontal wound is characterized

fundamentally by the epithelialization of the internal face of the flap
in contact with the radicular surface, forming the so-called long
epithelial attachment.

More apically, the maturation of the connective tissue reestablishes

the connective attachment, and, at the deepest point of the injury, it
is possible to detect a certain recovery of the bone architecture and
the periodontal ligament

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Reattachment and New attachment.

Reattachment is the attachment between two parts of previously

separated tissue, whether due to periodontal injury or to the
destructive process of periodontitis. This occurs when viable
ligament tissue still exists on the radicular surface, in such a way
that during healing this tissue is able to unite with the periodontal
fibers on the opposite side of the wound. This phenomenon may
arise during the healing of the deepest areas of the
periodontal pocket.

New attachment is used when this joining of tissues (epithelial

and/or connective) is produced on an area of the radicular surface
previously affected by periodontitis, and where no viable periodontal
tissue remained

Periodontal Regenerative TherapyWhen we speak of periodontal

regeneration, we usually refer to the partial regeneration (in height)
of the periodontium., complete regeneration of the periodontium
around whole circumference of the tooth is not abt to occure in
humanDuring tooth development, the periodontal stem cells
originate from the dental follicle cells, and are able to differentiate
in order to form radicular cementum, periodontal ligament, and
alveolar bone.

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Some of these stem cells remain in the periodontal
ligament after the tooth has fully developed. During the
healing of a periodontal wound, these stem cells, together
with those located in the perivascular region of the alveolar
bone, are stimulated to proliferate, migrate into the defect
and differentiate to form new cementoblasts, periodontal
ligament fibroblasts, and osteoblasts

Periodontal Debridement

This basic approach, whether achieved by nonsurgical disinfection

during closed debridement e.g., ( in periodontal pocket depths of up
to 5 mm) or by surgical debridement, can lead to the development
of a stable attachment apparatus, if not regeneration.

In advanced cases (e.g., cases of severe loss of horizontal alveolar

bone), healing after debridement procedures is not followed by
significant gains in new attachment

Surgical debridement of intraosseous defects appears to lead

predictably to an
increase in periodontal attachment of about 2.5 mm, with variable
amounts of bone filling (Polson 1978).

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Radicular (Root) conditioners

The radicular surface exposed to a periodontal pocket or to the oral

cavity presents bacteria, bacterial toxins or even changes in
mineralization .

Instrumentation of the root surface, however, results in formation of

a smear layer of organic and mineralized debris. The thickness of
this smear layer usually ranges from 2-15 μ is thought to serve as a
physical barrier between the periodontal tissues and the root
surface and may inhibit deformation of new connective tissue
attachment to the root surface .

1- A saturated citric acid solution

It is prepared by adding distilled water to the acid gradually until
the PH reached 1 and the prepared solution is continuously stirred
for 10 minutes .Acid is applied to root surface by cotton pellet for 3
minutes .

2- Tetracycline HCl solution

It is freshly prepared by adding a 500 mg capsule to 5 ml of distilled

water to result in 5% solution and the solution is continuously
stirred for 10 minutes .The solution pH is about 3.3.

3 - Ethylenediamine tetra acetic acid EDTA (pH 7.0) solution or gel

in 15%,- 20% concentration

EDTA not only preserves the vitality of the remaining periodontal

cells close to the root surface, but also removes calcium ions from
the collagenous dentin matrix more selectively (chelation) than low-
pH etching agents

4- Erebium Yttrium Aluminum Garne (Er:YAG laser)

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 Erbium laser ablates hard tissue through “microexplosion” rather
than heating the tissue resulting in minimal thermal effects

The results of histological studies in humans have been

contradictory,

A recent systematic review of the literature concluded that the

evidence to date suggests that using these chemical agents has no
significant clinical benefit for the patient with respect to the
reduction in probing depth or gain in clinical attachment level
(Mariotti 2003)).

Bone Grafting
It was thought that bone regeneration constituted a prerequisite for
the formation of a new attachment, and that the formation of new
bone would induce the formation of new cementum and periodontal
ligament

S0,different types of bone grafts and other materials have been

used to enhance bone regeneration

Indications

Periodontal pockets (intrabony) greater than 5 mm following phase I

therapy are difficult for patients to maintain and may be susceptible
to further breakdown. These areas should be evaluated and
considered for either pocket reduction or bone fill regenerative
surgery

Vertical bone loss with a resultant intrabony defect can result in

moat-shaped defects. These lesions, especially those with two or
three walls, respond well to bone fill regenerative procedures. Most
notably, guided tissue regeneration (GTR) with or without bone graft
materials

Furcations

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 In areas with furcations where there has been bone loss
extending apically less than 4 mm from the crotch of the furca, the
defect can be well managed with osseous surgery and apically
positioned flaps. This will result in a papillalike projection of gingival
tissue in the furcation with pocket depths of 2 to 3 mm.

Bone fill regenerative procedures do not provide significant

advantages for the Class I furcation defect with minimal bone loss.

Class III furcation defects do not respond well to bone fill

regenerative procedures.

If a tooth has lost 70% or more of its supporting bone volume and
has significant mobility (class 2+ or greater) following initial
therapy, then bone fill regenerative procedures have little, if any,
chance of success.

Patients with periodontal pockets that are not associated with

vertical bone loss (ie, intraosseous defects) should be managed with
surgery directed at reducing the suprabony pockets, such as flap
curettage, open flap débridement, or gingivectomy.

In the anterior portion of the mouth, it may be better to maintain

these areas with a nonsurgical approach if postsurgical gingival
recession would create an aesthetic compromise.

Bone-grafting materials
• Autograft ("Autogenous") the gold standard grafting material

• Allograft transplant within the same species

• Xenograft a cross-species transplantation

• Alloplast implantation of a synthetic material

Intraoral sources include

• Edentulous ridges, exostoses, tori,

• Healing extraction sites (8 to 12 weeks after extraction to allow

newly forming bone to mature),

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• Surgically created osseous defects,

• Implant osteotomy site,

• Maxillary tuberosity, and the Periodontal surgical site

Extraoral autogenous bone grafts may be harvested in large

quantities from the iliac crest.

• Frozen specimens are preferred because of the greater bone

apposition they demonstrate, a result of the cellular breakdown and
release of inductive substances that occurs during the freezing
process

• The postoperative complications associated with autogenous iliac

grafts, make autogenous iliac crest grafts an undesirable
alternative.

Autogenous graft may be cortical or cancellous.

• Cancellous bone contains a higher percentage of cells, and

therefore has more osteogenic potential.

• Cortical bone is believed to have higher levels of BMP's, and is

useful when structural support or three-dimensional augmentation
is required.

• Osseous coagula are grindings of cortical intraoral bone that were

mixed with blood

Advantage of autogenous bone graft:

• 1 - Presence of viable osteogenic cells within the graft

• 2- The remaining non-vital bone matrix serves as an

osteoconductive scaffold and is gradually replaced by "creeping
substitution",

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 3- It have osteoinductive activity As autogenous bone matrix is
broken down, bone morphogenetic proteins are released, resulting
in the attraction, differentiation and proliferation of bone forming
cells.

4- Autogenous grafts are nonimmunogenic

• Trephines for harvesting autografts

• 1- The edentulous maxillary tuberosity may be harvested where a

small amount of bone is required using small rongers

• 2- The use of an osseous coagulum trap

3- The use of a bone "scraper"

4- Trephines For use in harvesting bone

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 After harvest, the bone is morselized into small fragments
less than 1.0 mm in size and kept moist in sterile saline
until ready for use.

• Osteo-Crusher Hand-held bone mill used to create particulate bone

from harvested autogenous bone

Allografts

An allograft is a graft between genetically dissimilar members of the

same species.

Allografts used in periodontics are primarily in 2 forms:

Ffreeze dried bone allograft (FDBA)

Decalcified freezedried bone allograft (DFDBA).
The demineralization of the cortical bone improves the
osteoinductive potential by exposing bone morphogenic proteins,
and other inductive factors known to increase bone formation.

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They are available in unlimited amounts, and have osteoinductive
potential comparable with autogenous bone Grafting with
DFDBA has been shown to result in new attachment
apparatus characterized by new bone, cementum, and
periodontal ligament fibers

MinerOss® is a mixture of mineralized allograft cancellous and

cortical chips that

provide an osteoconductive scaffold to encourage bone growth.DFDBA

DFDBA

Grafton DBM Putty - network of DBM Fibers in a glycerol carrier

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Reginafil DFDBA

Xenografts Derived from animal sources.

Anorganic bovine bone is chemically treated to remove its organic

components, leaving a trabecular and porous architecture similar to
human bone.

Studies show that xenografts may have osteoinductive capabilities,

and there appears to be no difference between the clinical healing
of anorganic bovine bone and DFDBA.

Anorganic bovine bone may result in a gain in clinical attachment

accompanied by regeneration, especially when combined with the
use of an occlusive membrane

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 Xenografts

PepGen P-15 (received ADA Seal of Acceptance in May 2002)

Dentsply CeraMed Dental, Lakewood, Colo.

PepGen P-15 is a bone-grafting material that is composed of

anorganic bovine-derived hydroxyapatite bone matrix, or ABM,
combined with a synthetic cell-binding peptide, P-15. The P-15
peptide is a synthetic clone of a 15 amino acid sequence of the α1
chain of Type I human collagen (residues 766-780).

Pep-Gen P-15 combines 200 nanograms of P- 15 with 1 gram of ABM

and is available in particulate and gel form

Alloplasts

They are osteoconductive, inert biologic fillers. They include :

• Ceramics such as calcium phosphate (hydroxyapatite) and

tricalcium phosphate,

• Calcium sulfate (plaster of Paris),

• Calcium carbonates (coral)

• Bbioactive glass ceramics.

• “Calcium Hydroxide (oily solution) Osteora®MetaCura

GmbH,Munich)

• Hard tissue replacement Polymer (HTR polymer) BioplantTM

All these materials are biocompatible with host tissues, nontoxic,

nonallergenic and noninflammatory..

• Alloplasts are easy to obtain in large quantities and are relatively

inexpensive.

• Depending on the porosity and particle size, these materials may

allow bone conduction (bone growth in and around the alloplast),

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 but are generally not used for periodontal regeneration because
they become encapsulated by connective tissue and act only as
biocompatible space fillers.

• Healing adjacent to the root surface is mainly by a long junctional

epithelium, without restoration of periodontal structures.

These materials, therefore, are reserved for instances when

autogenous bone is not available and the patient objects to
the use of an allograft Deeper lesions respond better than
shallow defects

Success of Bone Replacement Grafts

• The outcome from bone replacement graft procedures depends upon :

Type of graft material used
• Initial defect morphology.(defect morphology is characterized by the
number of remaining osseous walls
• Three-walled defects respond better than 2- or 1-walled defects,
• Deeper lesions respond better than shallow defects
• The wider the angle between the root surface and the defect wall, the less
the potential for repair or regeneration .
• Optimal plaque control by the patient and appropriate surgical
management also are considered critical factors to success

Nanomaterials.

• Nanomaterials are those materials with components less than 100

nm in at least one dimension, including clusters of atoms, grains
less than 100 nm in size, fibers that are less than 100 nm diameter,
films less than 100 nm in thickness, nanoholes, and composites that
are a combination of these.

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• Nanocomposites usually exhibit much better performance properties
than traditional materials

• Another important feature of nanostructured materials is the

development of self-assembly.

• Nanomaterials are of interest from a fundamental point of view

because the properties of a material (e.g. melting point, electronic
properties, optical properties) change when the size of the particles
that make up the material becomes nanoscopic.

• Recently a synthetic Nanocrystalline hydroxyapatite (nano-HA)

paste (Ostim ,Heraeus Kulzer,Hanau ,Germany) containing 65%
water and 35% nanostructured apatite particles has been itroduced
for augmentation procedures in osseous defects

• Advantages of a nanostructured material are its close contact with

the surroundig tissues, quick resorption characteristics and a high
number of molecules on its surface

• It has been found that undisturbed osseous integration and

complete resorption of nano-HA paste occurs within 12 weeks,

• It increases the prolifration of human PDL fibroblasts significantly

• Its effect is linked to activation of EGF-R(Kasaj et al J Oral Sci

2008)

In intrabony defects, bone replacement grafts, result in

increased bone levels, less crestal bone loss, increased
clinical attachment gain, and greater probing depth
reduction (PDR) compared with open-flap debridement.

With the use of DFDBA, one of the most studied ,2.2 mm of

mean defect fill can be expected from bone grafting
procedures.

Other reviews suggest an average bone fill of 65%,

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Furcation defect fill depends on the morphology of the defect and
root configuration.

Increasing vertical bone loss, horizontal bone loss, and root

divergence results in a decrease in the expected percentage of bone
fill in the furcation.

The best results are in Class 2 furcations.

Bowers et al 2003 Autografts, DFDBA, and possibly xenografts result

in new attachment..

On the other hand, open flap debridement and alloplasts result in

periodontal repair characterized by a long junctional
epithelium.(Reynolds et al 2003)

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