Guided tissue regeneration in endodontics


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Guided tissue regeneration in endodontics

  1. 1. Guided tissue regeneration inGuided tissue regeneration in endodontic surgeryendodontic surgery
  2. 2. Regeneration of periodontal defects involves formation of new cementum, new attached periodontal fibers and new bone in a region previously destroyed by periodontal disease.
  3. 3. In principle,In principle, four methodsfour methods have been described tohave been described to increase the rate of bone formation and to augmentincrease the rate of bone formation and to augment the bone volumethe bone volume: osteoinduction: osteoinduction by the use of appropriatby the use of appropriatee growth factorsgrowth factors osteoconductionosteoconduction,, where a grafting material serves as a scaffoldwhere a grafting material serves as a scaffold for new bone growthfor new bone growth distraction osteogenesisdistraction osteogenesis ,, by which a fracture is surgically induced andby which a fracture is surgically induced and the two fragments are then slowly pulled apartthe two fragments are then slowly pulled apart and finally,and finally, guided tissue regenerationguided tissue regeneration , which, which allows spaces maintained by barrier membranes toallows spaces maintained by barrier membranes to be filled with new bonebe filled with new bone
  4. 4. Guided tissue regenerationGuided tissue regeneration The use of membranes to guide bony tissue formation by separating the underlying bone from Nonosseous cells (epithelial cells and fibroblasts) and space is preserved between the bone surface and membrane. Osteoblasts derived from the periosteum and bone are selectively induced on the osseous defect area, facilitating new bone formation.
  5. 5.  Guided tissue regeneration:  involves the placement of a barrier membrane to prevent cells other that PDL cells from migrating first to root surface  Guided bone regeneration:  involves the placement of a barrier membrane and a bone graft in the periodontal defect. Aim is to enhance bone formation
  6. 6. While GTR is for the regeneration of periodontal tissue of natural teeth GBR is for the regeneration of supporting bone
  7. 7. Historical review of GBRHistorical review of GBR  Regeneration of alveolar bone beneath cellulose acetate filler implant - by Boyne PJ. 1964  Healing of bone defects by GTR - by Dahlin C et al. 1988
  8. 8. Historical review of GBRHistorical review of GBR  Bone formation utilizing titanium-reinforced barrier membrane - by Jovanovic. 1995  Augmentation of intramembraneous bone beyond the skeletal envelope using an occlusive titanium barrier - by Lundgren D. 1995
  9. 9. Requirement ofRequirement of GBR barrier membraneGBR barrier membrane  Biocompatibility & safety  Cell occlusiveness  Space-making ability  Tissue integration  Clinical manageability & cost effectiveness - by Teparat T et al. 1998
  10. 10. Indication of GBRIndication of GBR  Extraction site - Prevention of crestal bone loss especially when 1 or more wall missing  Correction of inadequate ridge width or shape - Atrophic alveolar bone reconstruction for implant placement
  11. 11. Indication of GBRIndication of GBR  Dehicence defects  Apical fenestration  Residual intraosseous defects - Fresh or incompletely repaired extraction site
  12. 12. Nonresorbable membraneNonresorbable membrane  Titanium-reinforced expanded  polytetrafluoroethlene(Gorete)
  13. 13. Resorbable membraneResorbable membrane  Collagen barriers - Bio-Guide, Bio-Mend, Colla Tape  Synthetic polymers - Vicryl Mesh, Resolut, Resolut XT
  14. 14. Resorbable membraneResorbable membrane  Biologically active membrane: Platelet-rich plasma  Other barrier materials - Capset, Lambone
  15. 15. Bio-Gide: Composite Porcine Collagen Membrane
  16. 16. Bio-Oss:XENOGRAFT Protein extraction of bovine bone to produce porous bone mineral hydroxyapatite
  17. 17. Decalcified Freeze- Dried Bone (D.F.D.B.)Decalcified Freeze- Dried Bone (D.F.D.B.)  Variable osteogenic capacity  Viral particles killed in processing  Limited success in furcations  Available in particles and putty
  18. 18. BMPBMP  Highest concentrations  of BMP gave best clinical results
  19. 19. endodontic-periodontal lesion is a clinical manifestation of the pathologic inflammatory intercommunication between pulpal and periodontal tissues via open structures such as apical foramina lateral, accessory canals, and dentinal tubules ,
  20. 20. primary endodontic lesions, primary endodontic lesions withsecondary periodontic involvement primary periodontic lesions primary periodontic lesions with secondary endodontic involvement, true combined lesions Simon et al classifiedSimon et al classified endodontic-periodontal lesions intoendodontic-periodontal lesions into
  21. 21. The treatment of endodontic-periodontal combined lesions requires both endodontic therapy and periodontal regenerative procedure. The success rate of the endodontic-periodontal combined lesion without a concomitant regenerative procedure has been reported to range from 27%–37% (Hirsch JM1985). This is significantly lower than the reported success rate of 95% with conventional nonsurgical root canal therapy (imura 2007)
  22. 22. Guided tissue regeneration (GTR) therapy introduced in 1980s has been widely used to regenerate lost periodontium from periodontal disease. Both human and animal studies have demonstrated various degrees of regeneration of bone and attachment apparatus (Nyman S, Gottlow J, Karring T, Lindhe J.1982). GTR therapy has also been implemented in the endodontic surgeries as a concomitant treatment during the management of the endodontic-periodontal lesions (Schwartz 2006).
  23. 23. A treatment strategy for the application of the regenerativeA treatment strategy for the application of the regenerative procedures is outlined in Fig. 1 on the basis of theprocedures is outlined in Fig. 1 on the basis of the 26 successful cases reported (Schwartz SA, Koch MA 2006) .26 successful cases reported (Schwartz SA, Koch MA 2006) . 1. Treatment algorithm for periodontic-endodontic combined lesions
  24. 24. The presurgical assessment includes establishing and verifying the nonvital status of the pulp, the extent and severity of the periodontal destruction,. A localized deep probing depth with minimal tooth mobility might have a favorable clinical outcome after the regenerative procedure
  25. 25. Cortellini et al (2001) and others (Schulz A, Hilgers RD, Niedermeier W. 2004) have advocated splinting of the mobile tooth before GTR procedure because the baseline mobility has been associated with the smaller clinical attachment gain observed after GTR.
  26. 26. The intrasurgical assessment includes:  morphology of the periodontal defect,  defect type,  material of choice to fill the defect and augment healing,  wound stabilization
  27. 27. combination autogenous bone graft and e-PTFE membrane has been shown to result in the most favorable regenerative outcome
  28. 28.  A 50-year-old healthy,  nonsmoker female  Overall periodontal status was stable.  tooth #3 showed a localized deep probing depth of 9 mm  and a 5-mm gingival recession on the mesiopalatal aspect of the tooth with grade II mobility. y.  It responded to neither the electrical pulp test (EPT) nor the cold test
  29. 29.  no pain on percussion test  Periapical radiographic views showed a deep vertical bony defect extending to root apex of tooth #3, in addition to the periapical radiolucencies to the mesiobuccal root
  30. 30. Initial diagnosis was pulp necrosis and asymptomatic apical periodontitis, and the tooth was thought to have primary endodontic involvement. However, the pattern of periodontal bone loss, with a wide base coronally and narrow extent apically, suggested that there was also primary periodontal involvement in this case. Therefore, the overall classification of this case was an endodontic-periodontal combined lesion.
  31. 31. • RCT,SRP during control phase GTR after 1 month
  32. 32. Radiographic evidence of bone fill post surgery is not reliable because of variation in angulation of X-ray beam and variations in processing film between preoperative and postoperative radiographs.