Modern Clinical Procedures in Periodontal Reconstructive Treatment

Abstract

Reconstructive periodontal procedures improve tooth survival while reducing periodontitis progression and re-intervention needs providing long-term outcome stability. Even when periodontal attachment level is largely reduced, natural dentition yields better long-term survival rate and marginal bone level changes compared with dental implants. Periodontal regeneration is a complex biological process that involves de novo formation of the lost tooth supporting structures, including alveolar bone, periodontal ligament, and cementum over a previously diseased root surface. Clinically, periodontal regeneration may be achieved by application of barrier membranes, grafts, wound-healing modifiers, and their combinations. Currently, two preparations containing growth and/or differentiation factors are available for clinical application in periodontal regeneration procedures: enamel matrix derivative and platelet-derived growth factor mixed in a beta-tricalcium phosphate bone-replacement graft. Enamel matrix protein derivatives are, by far, the most largely evaluated in both preclinical and clinical models, and once applied on a denuded root surface start a cascade of biologic events that may finally lead to reconstitution of the periodontal apparatus. Patient characteristics, defect configuration, surgical technique, and maintenance therapy will determine success of periodontal regenerative procedures. Defect morphology plays a major role in healing following periodontal regenerative treatment. Adequate soft tissue management to achieve and maintain passive primary closure together with optimal wound stability over the regenerative materials is one of the most important factors for successful outcome of periodontal regenerative surgical treatments. Papilla preservation, modified papilla preservation, simplified papilla preservation, entire papilla preservation, and the single-flap approach have been widely quoted among the soft tissue management procedures. Combination therapy refers to the simultaneous application of various periodontal regenerative treatment alternatives to obtain an additive effect of different regenerative principles. Application of autogenous soft tissue grafts during periodontal regenerative treatment represents another type of combination therapy. Clinical outcomes obtained with periodontal regeneration can be preserved on a long-term basis, provided supportive periodontal treatment is regularly performed. In combined endodontic and periodontal lesions, after endodontic therapy is concluded, and in the presence of periodontal involvement, reconstructive periodontal therapy is the treatment of choice.