Guided tissue regeneration

GUIDED TISSUE
REGENERATION
K.NARENDHIRAN
MDS I Year

CONTENTS
• Introduction
• Melchers concept
• Guided tissue regeneration
• Definition
• History
• Ideal requirement of membrane
• Classification
• Indication & contraindication
• Healing of GTR
• complication
• Conclusion

INTRODUCTION
The objectives of periodontal
treatment are not only the control
of periodontal diseases but the
regeneration of periodontal tissue
destroyed by such diseases.
Periodontal regeneration is defined
as a reproduction or reconstruction
of a lost or injured part in such a
way that the architecture and
function of the lost or injured
tissues are completely restored.
(Glossary of periodontal term
1992)

RECONSTRUCTIVE
PERIODONTAL
PROCEDURE
NON BONE GRAFT
ASSOCIATED
BONE GRAFT
ASSOCIATED
• Removal of junctional or
pocket epithelium
• Prevention or impeding of
epithelial margin
• Bio modification of root
surface
GUIDED TISSUE
REGENERATION
Carranza’s Clinical Periodontology, 10th edition.

MELCHER’S CONCEPT
In 1976, Melcher suggested in a review paper that the type of
cell which repopulates the root surface after periodontal surgery
determines the nature of the attachment that will form.
Melcher AH. On the repair potential of periodontal tissue. J Periodontol 1976: 47: 256–260.

GUIDED TISSUE REGENERATION
• It is the method for the prevention
of epithelial migration along the
cemental wall of the pocket. GTR
consists of placing barriers of
different types to cover the bone
and periodontal ligament, thus
temporarily separating them from
the gingival epithelium.

DEFINITION OF GTR
Procedures attempting to regenerate lost periodontal structures through differential tissue responses. It
typically refers to regeneration of periodontal attachment. Barrier techniques, using materials such as
expanded polytetrafluoroethylene, polyglactin, polylactic acid, calcium sulfate and collagen, are
employed in the hope of excluding epithelium and the gingival corium from the root or existing bone
surface in the belief that they interfere with regeneration.
(Glossary of periodontal term 2001)
The AAP has defined GTR as “the procedure by which a barrier is utilized to exclude epithelium
from the root surfaces”.

HISTORY OF GTR
• Several decades ago, it was believed that bone was
the only tissue that played a role in supporting the
tooth within the alveolus, and that the ‘diseased
bone’ was primarily responsible for the presence
of angular (intrabony) or furcation defects arising
in periodontitis patients.
ROBERTSON,
1983; NYMAN
ET AL, 1984
• All treatment procedures aiming to regenerate
periodontal tissues resulted in the formation of a
long junctional epithelium on the instrumented
root surface, with no, or limited, formation of
cementum with inserting periodontal ligament
fibers
CATON ET
AL,1980
Anton sculean, iain l. C. Chapple & william v. Giannobile. Wound models for periodontal and bone regeneration: the role of biologic
research. Periodontology 2000, vol. 68, 2015, 7–20

• study in monkeys in which both gingival
connective tissue and gingival epithelium were
prevented from contacting the root surface during
healing by the use of a barrier membrane
GOTTLOW ET
AL. 1984
KARING ET
AL,1985
• Treatment of the first human tooth with GTR
NYMAN ET
AL. 1982
• proved in animal studies, granulation tissue from
periodontal ligament have the capacity to form new
cementum and bone.
Anton sculean, iain l. C. Chapple & william v. Giannobile. Wound models for periodontal and bone regeneration: the role of biologic research.
Periodontology 2000, vol. 68, 2015, 7–20

IDEAL REQUIREMENTS OF BARRIER MEMBRANE -
SCANTLEBURY, GOTTLOW AND HARDWILK (1982)
Biocompatibility
Space making
Tissue integrity
Cell occlusiveness
Mechanical strength
degradability
Guided tissue regeneration - Rationale and Factors affecting its outcome. (IOSR-JDMS) Volume 17, Issue 12 Ver. 6

CELLULOSE FILTERS
• Used in the initial studies (Nyman et al 1982, Gottlow 1984,
Magnusson et al 1985).
• Studies have found varying amounts of new connective
tissue attachment.
DISADVANTAGES
• Exfoliation.
• Tend to tear.
• Brittle.
• Difficult to manipulate

EXPANDED POLYTETRAFLUOROETHYLENE
MEMBRANE
• composed of a matrix of polytetrafluoroethylene (PTFE) nodes
and fibrils in a microstructure that vary in porosity.
• Maintain structural integrity
• Inertness and biocompatibility.
• e-PTFE has a porous structure that allows tissue ingrowth
• Nyman,Gottlow and Karring used ePTFE membrane and
found them to be predictable and standard.
• Gore-Tex Membrane (W.L Gore and Associates, Flagstaff,
AHZ) - most widely used material.
• It consists of 2 part – coronal border and occlusive portion

2 configuration
Transgingival design is used to treat
defects that are associated with structure
that extend through the gingiva.
Submerged design is used in situations
where there is no communication with
oral environment ,such as bony defects

HIGH DENSITY POLYTETRAFLUORO-
ETHYLENE (D-PTFE)
• A nonporous synthetic polymer is d-PTFE that does not allow ingrowth
of tissue
• Removal of d-PTFE is simple since there is no tissue ingrowth into
the surface structure.
• DISADVANTAGE:
Tendency for collapse of membrane towards defect.
Commercially available : Highdensity Gore tex, Cytoplast , Tefgen

TI-D-PTFE
• When clinical cases require larger areas of space
maintenance, a more rigid structure is required. To overcome these
challenges, a titanium-reinforced high-density
polytetrafluoroethylene (Ti-d-PTFE) or a titanium framework
placed in between two layers of e-PTFE may be utilized

TIMING AND PROBLEMS OF
MEMBRANE REMOVAL

ADVANTAGE AND
DISADVANTAGES
Exclusion of epithelial and
gingival connective tissue.
Maintains space between defect
and barrier allowing entry of cells
from PDL and alveolar bone
Helps to stabilize clot which may
enhance regeneration
Space maintainence over an
extended time and can remain in
place for longer period.
for 2nd surgical intervention to
retrieve the membrane.
Membrane exposure
Contamination
Infection

COLLAGEN MEMBRANE
• Collagen is a physiologically metabolized macromolecule of
the periodontal connective tissue
• properties: chemotactic and hemostatic
• This material is also a weak immunogen and may act as a
scaffold for migrating cells.
• favourable effects on coagulation and wound healing, high
tensile strength and fibre orientation.

ACELLULAR DERMAL
ALLOGRAFT
• A relatively new type of bioresorbable grafting material is cellular
human cadaver skin that has been obtained from tissue banks
• The material has undergone a process of de-epithelialization and
de-cellularization to eliminate the targets of rejection response,
leaving an immunologically inert avascular connective tissue

OXIDISED CELLULOSE MESH
• It is a commercially available resorbable haemostatic device which
can be used as a GTR device.
• When placed in contact with blood, oxidized cellulose converts to
a gelatinous mass (blood/membrane continuum), which has been
reported to potentiate osseous and soft tissue regeneration in
congenital maxillary cleft reconstructive surgery.
• Galgut,1990- used oxidized cellulose as a barrier in furcations and
interdental infrabony defects in one patient and reported a
reduction of probing depths and a gain of clinical attachment

POLYLACTIC ACID
• A bioresorbable matrix barrier composed of a blend of
polylactic acid that was softened with citric acid for malleability
and to facilitate clinical handling
• It was first resorbable barrier to be approved by the Food and
Drug Administration (FDA) for membrane barrier techniques.
• The layer that is in contact with the bone or tooth (the inner
layer) features small circular perforations and several space
holders to ensure enough room for the formation of new
attachment, whereas the layer in contact with the gingival
tissue(the outer layer) has larger rectangular perforations to
allow rapid ingrowth of gingival tissue into the interspace
between the two layers, preventing or minimizing epithelial
down growth
• Commercially available name- GUIDOR

ATRISORB
• A polymer of lactic acid, poly (DL-lactide) (PLA), dissolved in N-
methyl-2-pyrrolidone (NMP) has been studied as a resorbable
barrier material.
• The material begins as a solution that sets to a firm consistency on
contact with water or other aqueous solution
• This barrier has the advantage of being rigid enough for placement
but flexible enough to be adapted to the defect.
• The barrier adheres directly to dental structures; therefore sutures
are not required.

POLYGLYCOLIC & POLYLACTIC ACID
• Bioresorbable membranes made of polyglycolic acid (and
polylactic acid (Resolut, W.L. Gore. Flagstaff. AZ) have been
tested in experimental animals and proven to be safe with a
minimal inflammatory response and promotion of periodontal
regeneration.
• The random arrangement of the fibres and the openness of the
fibrous matrix encourage the in-growth of connective tissue and
inhibit apical migration of the epithelium.
• The fibre matrix is the primary structural component that provides
adequate strength for space making during the initial phases of
healing

VICRYL PERIODONTAL MESH
• It is woven mesh barrier made of polyglactin 910
• It is a copolymer of polyglycolic acid and polylactic acid with a
resorption rate of 30 to 90 days.
• several studies have questioned the use of polyglactin for guided
tissue regeneration (GTR) procedures, reporting that the mesh
provides an insufficient barrier because of fragmentation of the
material.
• The integrity of the mesh is lost after 14 days, and the cervical
sealing between the mesh and the adjacent tooth may not be
perfect.

INDICATION
• Vertical morphological defect
• Grade II furcation involvement
• Wide width of keratinized gingiva
• Increased gingival thickness
• Wider interdental spaces
• No mobility
• Good oral hygiene
• Alveolar ridge augmentation
• Repair of apicoectomy defect
• Osseous fill around immediate implant placement sites.
Periodontal surgery-A clinical atlas –Sato.N

CONTRAINDICATION
• Grade III furcations
• Premolar furcations
• Horizontal bone loss
• One walled intrabony defects
• Multiple adjacent defects
• Inadequate zone of attached gingiva
Guided tissue regeneration - Rationale and Factors affecting its outcome. (IOSR-JDMS) Volume 17, Issue 12 Ver. 6

FACTORS AFFECTING CLINICAL
OUTCOME
PATIENT
GTR
PROCEDURE
&HEALING
PERIOD
MORPHOLOGY
OF DEFECT
Pierpaolo cortellini& maurizio s. Tonetti. Focus on intrabony defects: guided tissue regeneration. Periodontology 2000, Vol. 22, 2000, 104–132

PATIENT
• Physiological, environmental behaviour and genetic factor
may affects the healing outcome of GTR
• Highly significant environmental exposure like
cigarette smoking, associated with reduced outcome
TONETTI ET AL,
1995
• Ability to maintain high level of plaque control
associated with improved outcome.
CORTELLINI ET AL,
1994
• The level of residual periodontal infection after initial
therapy influence the outcome
MACHETI ET
AL,1994

MORPHOLOGY OF DEFECT
GARETT,1988; TONETTI
ET AL, 1995
Greater amount of probing attachment and bone
gained in deeper defect
CORTOLLINI ET AL,1998 Defect deeper than 3mm results in greater probing
attachment gain.
TONETTI ET AL,1993 Wider defect associated reduced outcome
CORTOLLINI ET AL,1999 Radiographic defect of 25º gained more attachment
than defect of 37º
TONETTI ET AL,1993 Fails to demonstrate the association between
number of residual wall and clinical outcome
SELVIG ET AL, 1993 Clinical improvement associated with depth of three
wall defect
ANDEREGG ET AL,1991 Gingival thickness of less than 1mm high
prevalence of dehiscence

GTR PROCEDURE & HEALING
PERIOD
BECKET ET AL,1988 Membrane exposure is the major complication of GTR with
prevalence of 70 -80%
DESANCHTIS,1996;
GREVSTED,1993
Membrane exposure increases the bacterial contamination
MURPHY, 1996 Membrane exposure is reduced with use of specifically
designed flap to preserve interdental tissue.
FRANDSON,1994;
NOWZARI ET AL,1995
Antimicrobial prophylaxis is effective in reducing bacterial
load but ineffective in plaque formation

GTR PROCEDURE
Conventional
approach
Simplified
papilla
preservation
flap
Modified
papilla
preservation
technique
Interdental
tissue
maintenence
Crestal incision
Free gingival
graft

CONVENTIONAL APPROACH

MODIFIED PAPILLA
PRESERVATION TECHNIQUE

SUTURE TECHNIQUE
Horizontal crossed internal
mattress suture
Horizontal crossed internal
mattress suture - modification

SIMPLIFIED PAPILLA
PRESERVATION FLAP

SUTURE TECHNIQUE
Offset mattress suture

TREATMENT STRATEGIES

NON AESTHETIC SENSITIVE
SITE

AESTHETICALLY SENSITIVE
SITE

IN FURCATION
Karring and Cortellini 1999 Responed well to GTR
Jepsen et al. (2002) Greater reduction in horizontal furcation depth
Pontoriero et al. 1988;
Machtei et al. 1994
Buccal and lingual furcations respond equally well to
GTR treatment
Sanz and Giovannoli
(2000)
barrier membrane does not add any benefit when
compared with the OFD
Villar and Cochran 2010 Evidence indicates that GTR can be successfully used
only in the treatment of class II mandibular furcations
and has a limited clinical effect on class II maxillary
furcations

IN GINGIVAL RECESSION
Pini prato et al
,1996
Better results obtained by GTR in
the treatment of deep recession
and also increases the ketratinized
tissue width

HEALING AFTER GTR
• At wound closure, blood clot fills the space between the tooth
and flap. Within seconds plasma proteins primarily
fibrinogen precipitate onto the wound surfaces and provides
initial basis for adherence of fibrin clot.
• Within an hour, early inflammatory phase of healing is
initiated by neutrophils infiltrating the clot from the
mucogingival flap.
• Within 6 hours the root surfaces become lined by neutrophils,
which decontaminate the wound by phagocytising injured
and necrotic tissue.

• Within three days inflammatory reaction moves into its late
phase as neutrophil infiltrate gradually decreases while influx
of macrophages increase.
• Within seven days the phase of granulation tissue formation
gradually enters into third phase of healing in which newly
formed cell-rich tissue undergoes maturation and remodelling
to meet functional demands.

POST OPERATIVE REGIME
• Prescribe antibiotics for 5-7 days after surgery.
• Instruct the patient to return weekly for tooth cleaning until
membrane removal (usually 4-6 weeks).
• Let the patient brush with an ultrasoft toothbrush beginning 1
week alter surgery.
• chlorhexidine (0.2or 0.12 per cent solutions) applied twice or
three times daily until tooth brushing is resumed.
• If an interproximal-type membrane is used, postoperative
hygiene is especially important because membrane exposure
occurs earlier with this type than with other types

Remove membrane 4-8 weeks after surgery.
• Separate the membrane from the inner layer of the flap with a
partial-thickness incision.
• Reflect flaps, cut the knot suturing the membrane, and remove
the membrane carefully.
• Special care is required to avoid damaging new tissue
• Check that the membrane has been removed completely If part
of the membrane remains, it may cause abscess formation.
• Remove the epithelium covering the inside of the flaps before
suturing.
• Cover the new tissue with flaps and suture with silk thread. Place
a periodontal dressing.

COMPLICATIONS
pain
Purulence
Swelling
Sloughing
of flap
Tissue
perforation

Membrane exposure :
• Reported to be a major complication with prevalance of 50-100%.
Becker et al (1988), Cortellini et al (1993).
• Cortellini (1995) reported that prevalence of membrane exposure can
be highly reduced with use of access flaps specially designed to
preserve the interdental tissues.
• Exposure of the regenerated tissue to the oral environment
entails the risks of mechanical and infectious insults
• Order to achieve and maintain primary closure of the flap in the
interdental area, the modified papilla preservation technique
(MPPT)

CONCLUSION
• The principle of GTR lies in the establishment of the cells of
periodontal ligament to selectively repopulated the root surface.
• The use of GTR membranes can lead to significant periodontal
regeneration and formation of cementum with inserting fibers,
although complete regeneration has never been reported.
• It has considerable value as a regenerative procedure, particularly
in intrabony, furcation and gingival recession defects.

Guided tissue regeneration

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Guided tissue regeneration

Similar to Guided tissue regeneration (20)

Recently uploaded

Recently uploaded (20)

Guided tissue regeneration

Editor's Notes