PERIODONTAL REGENERATION

Straumann® Emdogain

1. HISTORY

The role of enamel matrix proteins in the development of cementum and periodontal tissues
1986
Lars Hammarström
Professor of Oral Pathology
Faculty of Dentistry, Karolinska Institute, Stockholm

  • 1988 Biora founded by Prof. Lars Hammarström, Karolinska Institute, Stockholm, Sweden
  • Production in Malmö since 1989
  • 1995 CE certification
  • 1996 FDA certification, the formation of subsidiaries in Germany and in the USA
  • 1998 Emdogain approved for sale in Japan
  • 2003 acquisition by Institute Straumann®
  • 2004 completion of integration by Straumann® Biologics
  • Delivered approximately 1,5 million units since production started
  • Used in over 800 000 patients worldwide
 

2. WHAT IS STRAUMANN® EMDOGAIN?

Enamel, dentin and cementum consist of different cells. Special cells build a matrix out of proteins (Enamel Matrix Proteins). The most important protein identified as Amelogenin.
 
Amelogenin (Straumann® Emdogain) is a biomimetic biology-based product, which promotes the re-growth of hard and soft tissues lost due to periodontal disease.
  
Straumann® Emdogain documentation
  • Over 60 published clinical studies demonstrate the efficacy of Straumann® Emdogain and its good treatment results
  • More than 1500 defects have been followed up in different clinical studies with Straumann® Emdogain
  • There is an average of 60-70% bone fill in defects treated with Straumann® Emdogain, measured one year postoperatively
 
What is Straumann® Emdogain?
  • Resorbable, implantable material
  • Enamel matrix protein (Amelogenin)
  • Gel for easy handling
What is Straumann® PrefGel?
  • pH neutral, 24% EDTA root conditioner
  • Removal of “smear layer” before the application of Straumann® Emdogain
  • Sold separately or co-packaged with Straumann® Emdogain
 
Epidemiology of periodontal diseases
Approximately 5% to 20% of any population suffers from severe generalized periodontitis even though moderate periodontal disease affects a majority of adults.
 
 

3. MODE OF ACTION

 
The concept used in a periodontal defect
Emdogain
Courtesy: F. Abbas, Amsterdam (Straumann® Education)
  1. The enamel matrix protein (EMD) forms a protein matrix on the root surface.
  2. Mesenchymal cells migrate into the lesion, attach to the surface and start to proliferate.
  3. Bone formation (osteogenesis) starts at the root
surface treated
with Straumann® Emdogain and subsequently new alveolar bone fills the defect.
  4. A new attachment with cementum and the periodontal ligament is formed along the treated root surface.
  5. New Dynamic functional attachment is achieved with time.
 
Straumann Emdogain® recreates previously lost attachment!

 
Desired effects of Straumann® Emdogain
  1. Epithelial growth: embankment
  2. Gingival connective tissue growth: embankment
  3. Bony growth
  4. Periodontal growth
  1. Cemental growth
  2. Wound healing & prevention of Bacteria
 
The basic concept of Straumann® Emdogain
Deposit of enamel matrix proteins onto a developing root surface is an essential step preceding the formation of cementum.
 

Pig tooth in development (Straumann® Education)
Formation of a periodontal ligament and alveolar bone is dependent on the formation of cementum.
Disease and different treatment results
Periodontitis       Repair           vs. Regeneration
 

Regeneration of Periodontal hard & soft tissue Defects
Treatment with Straumann® Emdogain 
  • Conditioning of root surface with Straumann® PrefGel.Application of Straumann® Emdogain (timescale: seconds).
  • Amelogenins precipitate out and matrix layer on the root surface is formed (timescale: seconds).
  • Formation of blood coagulum of fibrin and erythrocytes. Replaced by granulation tissue. Serves as a skeletal structure for wound healing and regeneration (timescale: hours).
  • Adduction and proliferation 
by mesenchymal cells (timescale: days).
  • Cells secrete natural and specific cytokines and autocrine substances which promote the required proliferation (timescale: weeks).
  • Attraction and differentiation to cementoblasts. Begin of formation of cement matrix in which desmodontal fibres will be fixed (timescale: weeks, months).
  • Anchorage of desmodontal fibres in the root surface (timescale: months).
  • Filling of the defect with newly formed desmodontal tissue (timescale: months).        
  • In connection with the processes, new alveolar bone grows on the root surface and into defect gap (timescale: months).
  • Regeneration of the desmodontium, building of new functional attachment.
 

4. CLINICAL INDICATIONS 


I. Treatment of periodontal intrabony defects
 
Single-wall defect              Two-wall defect          Three-wall defect
                                             
                               
       
The 1st visit                        8 years after treatment
Courtesy G. Heden, Karlstad (Straumann Education) 

II. Treatment of periodontal Furcation defects
 
Degree I.                                   Degree II.                        Degree III.
          
 
   
 
Characteristic of Severe furcation involvement:
  • horizontal bone loss
  • highly avascular target area
  • mesenchymal cell source far away
  • proper debridement difficult / impossible
 
Class II mandibular furcation defect
with minimal interproximal bone loss

Baseline                                  12-month follow up
Treatment with Straumann® Emdogain
 
 
 
 
 
 

 
III. Treatment of periodontal Recession defects  
Subepithelial connective tissue graft                             Straumann® Emdogain in conjunction with CAF
                                                                                        & Coronally Advanced Flap (CAF)
      
 
                                               
                                                               
Courtesy McGuire & Nunn, J Periodontol 2003;74:1110-1125 (Straumann® Education)
 
 
 

IV. SURGICAL PROCEDURE

Treatment of wider intrabony periodontal defects: Scaling, root-planning, and conditioning
 
                            
50% of 0,7 ml Syringe on root surface; 50% mixed with Straumann® Bone Ceramic Suturing; Straumann® EMD Plus application
 
Pre-surgical procedure
  • Careful patient selection:
  • Oral hygiene, smoking etc.
  • Cleaning, scaling, reducing the degree of inflammation
  • Follow up after 2-3 months, measurement of PD, tooth stability
  • Periodontal disease has to be eliminated
 
Pre-surgical procedure
  • Remove any remaining plaque and/or calculus as well as blood from root surfaces exposed during
  • periodontal surgery
  • Apply Straumann® PrefGel onto exposed root surfaces for 2 minutes
  • Rinse thoroughly with sterile saline solution
  • Avoid recontamination of the conditioned root surfaces after the final rinse and prior to treatment with Straumann® Emdogain
 
Postsurgical follow-up & maintenance
Day of operation:
  • Start rinsing with chlorhexidine solution (0,2 - 0,12%)
  • Refrain from/minimize smoking
  • Do not brush the area of the operation
  • Avoid hard and crispy food
  • (Antibiotics, if deemed appropriate based on the clinician’s judgement)

  • Wound stability & infection control
 
Week 1 postoperative:
  • Removal of sutures which no longer add to the stability of the healing wound
  • “Professional tooth cleaning” as needed
  • Continue to rinse with chlorhexidine solution (or apply chlorhexidine gel locally in the operated area).
 
2 - 6 weeks postoperative:
  • Removal of any remaining sutures
  • “Professional tooth cleaning” as needed
  • Continue to rinse with chlorhexidine solution (or apply chlorhexidine gel locally in the operated area)
  • Week 4 start careful tooth-brushing in the operated area on buccal/lingual surfaces, but not interproximally
 
6 weeks postoperative:
  • Stop rinsing with chlorhexidine
  • “Professional tooth cleaning” as needed
  • Start interproximal tooth cleaning in the operated area
  • Fluoride application as needed
  • Decide on a subsequent (individual) recall schedule
 
6 - 12 weeks postoperative:
  • Adequate tooth cleaning in the operated area
  • Decide on a subsequent (individual) recall schedule
  • X-rays at 12 months
 
  • No probing before 6 months!
  • Follow-up radiographs at 12 and 24 months
  • Individual recall program
 

V. PLUS Straumann® Emdogain

Bone & periodontal attachment regeneration 
Toolbox” for oral tissue regeneration

 
What is Straumann® Emdogain PLUS?
Straumann® Emdogain consists of amelogenin for periodontal regeneration
Straumann® BoneCeramic is used for filling and/or augmenting intraoral/maxillofacial osseous defects
 
Straumann® Emdogain + Straumann® BoneCeramic is indicated for:
  • Augmenting intraoral/maxillofacial osseous defects
  • Bony defects of the alveolar ridge
  • Tooth extraction sites
  • Pneumatized sinus
  • Intrabony periodontal osseous defects and furcation defects
Optimal characteristics of bone substitutes:
  • Morphology determines: vascularisation & osteoconduction
  • Composition determines: degradation & biocompatibility
  • De; gradation determines: replacement (substitution) of bone filler material by bone
  • Straumann® BoneCeramic gets close to the optimal characteristics of a bone substitute: Optimized 3D structure morphology; Osteoblast-friendly topography (osteoconductive)
  • Fully synthetic composition: no risk of transfection, reproducibility; Controlled” degradability

            HA protects excessive resorption, TCP initiates mineralization
 
Tooth replacement
                      
Extraction site                          Dehiscence & fenestration     Straumann® BoneCeramic granules
 
  
Localised ridge atrophy                      Pneumatised sinus      Red staining showing newly formed bone at
                                                                                                augmented site with Straumann® BoneCeramic 
                                            granules. (Courtesy: Mellonig et al. 1995.                                                                                              University of Bern
                                                                                                (Straumann® Education)
 
  
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