Decision Trees in Periodontal Surgery: Resective Versus Regenerative Periodontal Surgery
Traditionally, periodontal surgical procedures such as osseous resective surgery and open flap debridement have been used as a treatment modality in order to control the progression of periodontal disease. The advent of new tools such as microscopes, cone
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Decision Trees in Periodontal Surgery: Resective Versus Regenerative Periodontal Surgery Aniruddh Narvekar, Kevin Wanxin Luan, and Fatemeh Gholami
2.1
Introduction
For decades, clinicians and researchers have aimed to develop therapies to predictably regenerate periodontal structures and regain attachment lost due to periodontal disease. The advent of new surgical procedures, growth factors, and other biomimetic agents to complement existing bone replacement grafts has fundamentally changed the field of regenerative dentistry by increasing the long-term survival rate of teeth often categorized as having a poor prognosis. In the last decade, several new techniques have been demonstrated both preclinically and clinically, to further improve the success rate of periodontal regeneration.
2.2
Clinical Decision Considerations
Guided tissue regeneration (GTR) was formally introduced by Isidor et al. [1] where an occlusive membrane was utilized to allow only cells from the periodontal ligament to repopulate the root surface. The concept of cell occlusion and space provision prevented the gingival epithelium and connective tissue from entering the defect. Since then, the need for an occlusive membrane for defect isolation has been questioned by several authors, and the focus has shifted to the role of the undisturbed fibrin clot and wound stabilization between the tooth and gingival flap to prevent the downgrowth of epithelium [2, 3]. Based on current evidence, the predictability of GTR procedures has been shown to be influenced by several factors related to the defect site such as intrabony defect
A. Narvekar (*) · K. W. Luan · F. Gholami Department of Periodontics, College of Dentistry, University of Illinois at Chicago, Chicago, IL, USA e-mail: [email protected]; [email protected]; [email protected] © Springer Nature Switzerland AG 2020 S. Nares (ed.), Advances in Periodontal Surgery, https://doi.org/10.1007/978-3-030-12310-9_2
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depth, angle, and configuration. According to Reynolds et al. [4], narrow defects less than 3 mm in width show a higher gain in attachment level, and bone fill suggesting defects which were shallow and wide would benefit more from osseous resective surgery. Indeed, several authors have consistently shown deep intrabony defects greater than 3 mm to have improved clinical outcomes using GTR compared to shallow defects [5, 6]. As our understanding of wound healing and periodontal regeneration has improved, a shift in treatment strategy from primarily one of cell occlusion to blood clot stability has occurred. Several minimally invasive surgical procedures have been introduced with the primary objectives of minimal flap reflection, wound stabilization, and establishing primary closure of the surgical flap(s). These approaches have demonstrated similar clinical outcomes irrespective of the defect configuration. The use of microsurgical instruments and microscopes has allowed for smaller surgical flaps with more predictable flap positioning, thereby stabilizing the bloo
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