California Continuing Education Credits: 4 units
COURSE OUTLINEProcurement and preparation of the graft: If allografts or alloplasts are being used, they are mixed with saline or water to a firm paste that can be easily worked with. Tetracycline powder can be added to the graft material because of its antibiotic effect during the initial period of the healing. It has not been shown that tetracycline addition to the graft is beneficial, although it is believed by some. If an intraoral autograft is being used, it has to be retrieved with a trephine burr, rongeurs or with a large elevator and a high speed functioning with little irrigation. The elevator is used as a backboard to collect bone while using the high speed burr on the bone surface. Tetracycline can also be used (3 parts of bone to 1 part of tetracycline).
Placement of the graft in the osseous defect: the graft material should be condensed tightly in place with amalgam condensers. Care should be taken for grafts not to be overfilled to avoid exposure due to soft tissue shortage.
Flap margins coapted and sutured (mattress sutures): this is a very important step. Primary closure of the flaps is desirable. There should be no voids between the buccal and the lingual flaps or part of the graft material will be exposed. Excessive suture tensions should not be placed on flaps to avoid necrosis. Mattress sutures are the most suitable ones since they minimize contact of the suture material with the graft which will in turn minimize oral bacteria from coming in contact with the graft by capillarity. Synthetic sutures are better than silk because they have less capillarity.
This is the radiograph of this case before the graft was placed and this is a radiograph of the case about one year later Notice complete bone fill between teeth #šs 28 and 29 and about 2/3 of bone fill between teeth #šs 29 and 30, where a residual defect is was present. Radiographically, it cannot be said that true regeneration took place. Clinically, treated lesions are evaluated in terms of pocket depth and attachment level. A previous pocket which does not probe after treatment is considered a success. True periodontal regeneration could only be confirmed by histologic evaluation which, for obvious reasons, cannot be routinely done.
Since this was a research case, a reentry surgery was performed. It is important to remember that reentry surgeries are not routinely performed on patients. Notice the osseous defects before treatment and 1 year after treatment where a significant amount of bone fill is observed.
All efforts to minimize bacterial plaque build-up in the grafted are should be emphasized. This includes 0.12% chlorhexidine rinses 2-3 times per day for 2-3 weeks and systemic antibiotics for 2-3 weeks. In selecting an antibiotic, the clinician would like to have one that achieves high concentrations in the crevicular fluid; antibiotics from the tetracycline family have been shown to do that. The dosage and regimen for tetracycline are 250 mg four times per day and for doxycycline (a tetracycline derivative) are 100 mg 2 times per day. Penicillin and its derivatives can also be used. An analgesic medication should also be prescribed.
Suture removal should be performed between 7 and 10 days. The patient is instructed to initiate oral hygiene in the area and is examined every 15 days for the next 3 months.
During these examinations, light debridment of the area is performed. No probing or vigorous scaling of the grafted are should be performed for at least 3 months following surgery.
Radiographic control of the area should be initiated at 6 months. Autografts and mineralized alloplasts can be visualized on radiographs immediately following surgery; decalcified materials (DFDBA, i.e.) will not be radiographically detected for at least 6 months.
The following parameters should be evaluated following surgery and compared to preoperative values:
True new attachment vs. long junctional epithelium: once again, this difference is histological and cannot be detected clinically or radiographically. Even though the ideal interface between the alveolar bone and the root surface is new attachment, pocket depth resolution, attachment gain, and radiographs are indicators of success and they do not address the presence of one particular modality of attachment.
The susceptibility to periodontal breakdown for long junctional epithelium and new attachment has not been determined.