Guided tissue regeneration

Guided Tissue Regeneration
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 INTRODUCTION
 TERMS
 GUIDED TISSUE REGENERATION (GTR) – HISTORY
 PERIODONTAL WOUND HEALING
 GUIDED TISSUE REGENERATION – THE CONCEPT
 CLASSIFICATION OF GTR MEMBRANES
 CHARACTERISTICS OF GTR MEMBRANES

 INDICATIONS & CONTRAINDICATIONS FOR THE USE OF GTR
MEMBRANES
 COMPARISON OF GTR MEMBRANES
 GUIDED TISSUE REGENERATION (GTR) IN PERIODONTAL TREATMENT:
- Intrabony defects (IBDs)
- Furcation
- Recession
o COMPLICATIONS
 TRENDS WITH GTR MEMBRANES
 CONCLUSION
 REFERENCES

- Periodontal disease is defined as a complex,
multifactorial disease characterized by the loss of
connective tissue attachment with destruction of
periodontal tissues.
- The aim of periodontal therapy is to :-
1) Eliminate inflammatory process,
2) Prevent the progression of periodontal disease and
also
3) To regenerate the lost periodontal tissues.
- Periodontal regeneration is a complex multifactorial
process involving biologic events like cell adhesion,
migration, proliferation, and differentiation in an
orchestrated sequence (Giannobile WV 1996).

According to position paper by AAP, Periodontal
regenerative procedures include:
Soft tissue grafts
Hard tissue
grafts
Root
biomodifications
Guided tissue
regeneration
Combination of
these
procedures

•Regeneration: defined as the reproduction or constitution of a lost
or injured part to restore the architecture and function of the
periodontium (American academy of periodontology 1992).
•Regeneration: Reproduction or reconstitution of a lost or injured
part. (GPT 2001)
•Periodontal regeneration: defined as the complete restoration of
lost tissues to their original architecture and function by
recapitulating the crucial wound-healing events associated with
development (Polimeni G, Xiropaidis AV, Wikesjo UM. Biology and principles of
periodontal wound healing ⁄ regeneration. Periodontol 2000 2006;41:30–47).
•Repair: Healing of a wound by tissue that does not fully restore
the architecture or the function of the part.

•Bone fill: The clinical restoration of bone tissue in a treated periodontal defect.
Does not address the presence or absence of histologic evidence of new
connective tissue attachment or the formation of a new periodontal ligament.
•Attachment, new: The union of connective tissue or epithelium with a root
surface that has been deprived of its original attachment apparatus. This new
attachment may be epithelial adhesion and/or connective adaptation or
attachment and may include new cementum.
•Reattachment: To attach again. The reunion of epithelial and connective tissue
with a root surface. Not to be confused with new attachment.
•Periodontal reconstruction: refers to the process of regeneration of cells and
fibres and remodelling of the lost periodontal structures that results in (1) gain
of attachment level, (2) formation of new periodontal ligament fibres, and (3) a
level of alveolar bone significantly coronal to that present before treatment.
•Epithelial adaptation: differs from new attachment in that it is the close
apposition of the gingival epithelium to the tooth surface, with no gain in height
of gingival fiber attachment.

The 1996 World Workshop in
Periodontics defined GTR as :
“procedures attempting to regenerate
lost periodontal structures through
differential tissue responses. Barriers
are employed in the hope of
excluding epithelium and gingival
corium from the root surface in the
belief that they interfere with
regeneration”.

Guided Tissue Regeneration – History
Use of barrier membranes to direct bone regeneration was first
described in the context of orthopaedic research by Hurley et al
(1959)
The theoretical principles basic to guided tissue regeneration (GTR)
were developed by Melcher in 1976
The first application of barrier membranes in the oral cavity was
by Nyman(1980), Lindhe, Karring (1980) and Gottlow (1984) in
the context of regeneration of periodontal tissues via GTR, as an
alternative to resective surgical procedures to reduce pocket
depths

The first GTR membrane used in the periodontal surgery was
cellulose acetate laboratory filter paper by Nyman et al. in
1982.
Treatment of first human tooth with GTR was reported by
Nyman et al (1982)
Guided Tissue Regeneration – History
Gottlow et al coined the term Guided Tissue Regeneration
Earliest attempts of GTR – Millipore filter- 1971-Dienes,cohen.
Ellegard (1974) -free gingival frafts
Becker et al (1988) - ePTFE
Cortelleni (1994) - Rubber dam

Biological basis for GTR: Specific cell
repopulation theory Melcher(1962,1976)
a) Long junctional
epithelium
c) Ankylosis with
radicular resorption
b) Connective
attachment with
radicular resorption
d) Periodontal
regeneration

Bone cells
Gingival
connective
tissue cells
Periodontal
ligament
cells
Epithelial
cells
To assess the regenerative capacity of :

Whether progenitor cells for periodontal attachment formation
reside in the periodontal ligament ...???
• In their experiments observed root
resorption occasionally in the apical
portion of extracted and re-
implanted teeth.
• It was suggested that, PDL was
injured in those areas of the roots.
Karring et al
(1980) ;
Nyman et al
(1980)
• Study on periodontally involved
roots retained in their sockets &
submerged, significant amount of
new connnective tissue attachment
was formed on the coronal portions
of the roots.
• This was seen to be associated on
only roots with a non-impaired PDL
Karring et al
(1985)

Whether progenitor cells for periodontal attachment formation
reside in the periodontal ligament ...???
Buser et al 1990;
Warrer et al
1993
Studies on placing
titanium implants in
contact with retained
root tips and control
implants placed without
contact with retained
roots.
Microscopic analysis
revealed that a distinct
layer of cementum with
inserting collagen fibres
had formed on the
surfaces of the implants in
contact
Parlar et al
(2005)
A novel and unique
experimental model in
dogs.
Histologic analysis after 4
months of healing revealed
that a PDL, bone and root
cementum had formed
between the implant & the
dentinal wall of the chamber,
over which the collagen
barrier was placed.

GUIDED TISSUE REGENERATION -
THE CONCEPT...!!!

Basis for the clinical application of the treatment principle termed
“Guided Tissue Regeneration”
A study on monkeys in
which both gingival
connective tissue &
gingival epithelium
were prevented from
contacting the root
surface during healing
by the use of barrier
membrane
After reduction of the
supporting tissues around
the selected
experimental teeth, root
surfaces were exposed to
plaque accumulation for
6months, then soft tissue
flaps were raised,
exposed root surfaces
were curetted, teeth
were resected and roots
were submerged.
Before complete
closure, barrier
membranes were
placed on one side
of the jaws & no
membranes were
placed over the
contralateral roots.
Histologic analysis
after 3 months of
healing demonstrated
that the roots covered
with membranes
exhibited
considerably more
attachment than the
non-covered roots
Gottlow et al 1984

Nyman et al (1982)
• First report of a human tooth
treated according to the
principle of GTR.
• At the surgical procedure, a
periodontal defect was
diagnosed that measured 11
mm from the CEJ to the
bottom of the defect.
• Three months following GTR
treatment, the tooth was
removed as a whole together
with its buccal periodontium.
• The histological analysis
demonstrated new
connective tissue attachment
extending 7 mm coronally, as
measured from the bottom of
the previous defect.
Gotlow et al (1986)
• 12 patients were evaluated
clinically and in 5 of these,
histologic documentation was
presented.
• Teflon membranes, made of
expanded poly-
tetrafluoroethylene (PTFE)
(GORETEX) was used.
• The results showed that
varying but considerable
amounts of new connective
tissue attachment had
formed on all treated teeth,
confirming the hypothesis
that GTR regenerates lost
attachment.
Basis for the clinical application of the treatment principle termed
“Guided Tissue Regeneration”

GTRtreatmentinvolvestheplacementof a “physicalbarrier”to ensurethattheprevious
periodontitis-affectedrootsurfacebecomesrepopulatedwithcellsfromtheperiodontalligament.

Characteristics or design criteria of GTR membranes
Biocompatibility
Cell exclusion
Cell occlusivity
Space
maintenance
Tissue
integration
Ease of use
Scantlebury (1993)

Other qualities of an ideal barrier membrane are:
Non-toxic and non-carcinogenic
Chemically inert and non-antigenic
Easily stored and have a long shelf life
Preferably resorbable
Easily retrievable in case of complications
Not be too expensive
Easily sterilizable
Should fulfill the occlusive requirements of GTR concept.

-Grade II furcation defects and 2- or 3-walled
vertical interproximal and circumferential
intrabony osseous defects.
-Grade III furcations with a vertical component,
can also be treated with this technique, but the
predictability of success is decreased.
- A loss of clinical attachment of at least 4-5 mm
should be present to warrant this procedure.
-Areas with abundant gingiva are preferred to
facilitate flap management and barrier
coverage.
-Areas prone to postsurgical recession are best
treated with nonresorbable barriers since
barrier exposure may accelerate resorbable
barrier degradation.
- Alveolar ridge augmentation.
INDICATIONS OF GTR

CONTRAINDICATIONS (Wang & Cooke – DCNA – 2005)
Any medical condition contraindicating surgery.
Infection at defect site
Poor oral hygiene
Defect depth< 4mm with <1mm width of attached gingiva at
defect site
Thickness of gingiva <0.5mm at the defect site
Tooth mobility>1mm
Furcation with short root trunks
Generalized horizontal bone loss
Advanced lesions with multiple defects

CLASSIFICATION OF GTR MEMBRANES
Minabe (1991)
Non-absorbable
Polytetrafluoroethylene type
(ePTFE)
-GORE-TEX regenerative
materials (WL Gore)
Titanium reinforced polytetra-
fluoroethylene type
- Titanium reinforced e-PTFE
membrane (WL Gore)
Absorbable
Collagen type
-Koken tissue guide (Koken)
-Paroguide (Lyon)
Synthetic polymer type (lactate-glycol
compound)
-GC membrane (GC)
-Resolute (WL Gore)
-Vicryl (Ethicon)
-Atrisorb (Atrix)
-Guidor (Guidor)

CLASSIFICATION OF GTR MEMBRANES
Gottlow
(1993)
Third generation
(resorbable with
growth factors)
Growth factors help
in regeneration of
tissues
First generation
(nonresorbable)
•Millipore filter
•Expanded
polytetrafluoroethylene
(ePTFE) membrane (Goretex)
•Nucleopore membrane
•Rubberdam
Second generation
(resorbable)
. Collagen membrane
. Polylactic acid membrane
(Guidor)
. Vicryl mesh (Polyglactin
910)
. Cargile membrane
. Oxidized cellulose
. Hydrolysable polyester

Non- absorbable membranes
- e PTFE
-One of the first ADA approved barrier membranes consists of
Fluorocarbon polymer.
-Manufactured by subjecting PTFE to high tensile stress, forming
porous microstructure of solid nodes and fibrils resulting in better
physical structure and strength .

JiaolongWang, Lina Wang, Ziyu Zhou, Hanjian Lai, Pan Xu, Lan Liao,Junchao Wei. Biodegradable
Polymer Membranes Applied in Guided Bone/Tissue Regeneration: A Review. Polymers 2016;8:115.

ADVANTAGES DISADVANTAGES
•Structural integrity-
Prevents soft tissue collapse
& space provision
•Ease of use
•Long track record of
effectiveness
•Option of titanium
reinforced variety for
rigidity enhancements
•Require second surgery for
removal- increase cost, time
& morbidity
•Less tissue integration-
increased exposure &
bacterial contamination of
membrane

Absorbable barriers
Desirable properties of an absorbable barrier material:
- Preserve and maintain the space and conform to defect shape
- Ability to be customized for unique situations
- Adherence to or ability to approximate the root surface
- Ability to adhere to the root or be stabilized against it
- Promotes tissue coverage and reduced barrier exposure rates
- Promote flap attachment at surgery
- Resists bacterial seeding and contamination
- Promotes selective cell proliferation within the defect
- Promotes natural or induced cellular filling of the defect by
progenitor cells
-Absorbs at a rate that parallels regenerative tissue formation (4 wk-6
months)
Wang HL, MacNeil RL. Guided tissue regeneration. Absorbable barriers. Dent
Clin North Am. 1998 Jul;42(3):505-22.

Advantages: Limitations
Hemostatic function
Chemotactic to PDL
fibroblasts.
Weak immunogenicity.
Easy manipulation .
Ability to augment tissue
thickness.
Superior to non resorbable
barriers with regard to healing
Incorporation of
antimicrobials into barrier not
beneficial
Can elicit immunologic &
inflammatory reactions .
Less working time
Less rigid when compared to
e-PTFE membranes

Collagen membranes
Are the most popular barriers used in both GTR and GBR
procedures, and the collagen for such purposes is available from
different animal sources, especially porcine and bovine (C. Stoecklin-
Wasmer, A. W. S. Rutjes, B. R. Da Costa, G. E. Salvi, P. Jüni, and A. Sculean, “Absorbable collagen
membranes for periodontal regeneration: a systematic review,” Journal of Dental Research, vol. 92, no. 9,
pp. 773–781, 2013)

Collagen membranes for guided tissue regeneration (GTR) procedures:-
o Have been shown to be comparable to non‐absorbable membranes with
regard to probing depth reduction, clinical attachment gain, and percent of
bone fill.
oAlthough these membranes are absorbable, collagen membranes have
been demonstrated to prevent epithelial downgrowth along the root
surfaces during the early phase of wound healing.
oThe use of grafting material in combination with collagen membranes
seems to improve clinical outcomes for furcation, but not intrabony,
defects when compared to the use of membranes alone.
oCollagen materials have also been applied in guided bone regeneration
(GBR) and root coverage procedures with comparable success rates to
non‐absorbable expanded polytetrafluoroethylene (ePTFE) membranes and
conventional subepithelial connective tissue grafts, respectively.
Long‐term clinical trials are still needed to further evaluate the benefits of
collagen membranes in periodontal and peri‐implant defects.
Dr. Pintippa Bunyaratavej, Hom‐Lay Wang. Collagen Membranes: A Review. J Periodontol 2001;72:215‐229.

NAME SOURCE RESORPTION
RATE
Biobar Bovine tendon (type I
collagen)
24-32weeks
Paroguide Calf skin 4-8weeks
Various available collagen membranes

A biodegradable polylactic acid (PLA)/poly(glycolide-co-
lactide) copolymer (PLGA) membrane with polyglycolic acid
(PGA) mesh:
o Microporous membrane
o Based on the albumin permeation test, it is known that the
biodegradable membrane exhibits the suitable permeability of
nutrients.
o The membrane maintained its physical integrity for 6-8
weeks, which could be sufficient to retain space in the
periodontal pocket.
o Cell attachment and cytotoxicity tests were performed with
respect to the evaluation of biocompatibility of the membrane.
As a result, the membrane did not show any cytotoxicity.
Eun Jin Kim et al 2009

VICRYL
Copolymer of polyglycolic acid and polylactic acid.
Resorption rate of 30 to 90 days.
Results of 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, allowing for the growth of connective tissue epithelium
between the root surface and the barrier.
Jacob SA, Amudha D. Guided tissue regeneration: a review. J
Dent Health Oral Disord Ther. 2017;6(3):67-73.
DOI: 10.15406/jdhodt.2017.06.00197

Atrisorb –
 A polymer of lactic acid, poly (DL-lactide) (PLA), dissolved in N-
methyl-2-pyrrolidone (NMP).
 barrier adheres directly to dental structures; therefore sutures
are not required.
 Because of its semi rigid property in the extra oral environment,
this barrier has the advantage of being rigid enough for
placement but flexible enough to be adapted to the defect.
 The polymer composition is similar to that of Vicryl sutures
(Ethicon Inc). When outside the oral cavity, the membrane is a
partially set solution which allows it to be trimmed to the
dimensions of the defect before intraoral placement. The barrier
is then adapted to the defect and sets in a firm consistency in
situ.
Jacob SA, Amudha D. Guided tissue regeneration: a review. J Dent
Health Oral Disord Ther. 2017;6(3):67-73.
DOI: 10.15406/jdhodt.2017.06.00197

Mechanism of degradation
Proteolytic degradation (Gottlow 1993, Lundgren et al.
1994).
Proteolytic enzymes released from PMN: Collagenases,
gelatinases, peptides
Liberation of myeloperoxidase as a potent injurious
oxidative enzyme
Non enzymatic cleavage of polymer to polylactide and
polyglycolide which is converted to lactic acid and
pyruvate which in turn is metabolized by Krebs cycle.

Degradation by GTR Membranes by periopathogens
Nowzari et al. (1995)- showed that P. gingivalis could be detected in sites with loss of
probing attachment after e-PTFE membrane removal. They also demonstrated that Prevotella
intermedia, Peptostreptococcus micros, and Campylobacter rectus constituted high
proportions of the bacteria found on membranes in sites demonstrating little or no
attachment.
Machtei et al. (1994) - suggested that the amount of bacteria found on regeneration
membranes may be used as a predictor of the outcome of the regenerative treatment.
The presence of enzymes like Rgp, Kgp, and the prolyl peptidases in P. gingivalis
together with their ability to adhere to collagen membranes (Sela et al. 1999)
may explain the role of these oral bacteria in the degradation of GTR collagen
membranes.
Tal et al. (2008) - who evaluated long-term barrier bio-durability of cross-linked
and non-cross-linked collagen membranes in sites treated by GTR procedures have
found that cross-linked membranes were more resistant to tissue degradation.
Sela MN et al (2009) - results suggest that the presence of P. gingivalis cells,
extracellular vesicles and enzymes in the vicinity of regeneration membranes in the
periodontium, may change their physical structure and therefore alter their biological
properties. Furthermore, the use of cross-linked collagen membranes and antibacterial
agents may significantly inhibit this proteolytic process.

GUIDED TISSUE REGENERATION (GTR) IN PERIODONTAL TREATMENT:
The overall treatment rationale of applying guided
tissue regeneration in deep intrabony defects :-
“comes from the need to increase the periodontal
support in teeth severely compromised by
periodontal disease”

The turning point in the guided tissue regeneration arena was the
year 1993 :-
When the clinical outcomes of a group of 40 intrabony defects
treated with non-resorbable expanded polytetrafluoroethylene
membranes were analyzed with a multivariate statistical approach
with the aim of isolating the relevant variables that could influence
the healing response and the final clinical outcomes of guided
tissue regeneration (Cortellini P, Pini-Prato G, Tonetti M, Williams RC, 1993,1994,
1996)
The results from the cited studies demonstrated that the variability
in clinical outcomes was affected by patient-, defect- and
procedure-associated factors.
Understanding the factors determining the clinical outcomes
rendered their control, at least in part, possible, allowing
remarkable improvements in their extent and predictability.

Guided tissue regeneration as a multifactorial treatment approach
comprising :-
Careful selection of
patients
Type of defects
Surgical technique
Type of membrane and
adjunctive material
Suturing approaches

Modified from Cortellini & Bowers. Int
J Periodontics Restorative Dent 1995

Modified from Cortellini & Bowers. Int
J Periodontics Restorative Dent 1995.

Surgical technique
Conventional approach
Does not allow a complete
preservation of the interdental
papilla, therefore rendering very
difficult the primary closure of
the interdental tissues over the
membrane.
Major complications are gingival
dehiscence and membrane exposure.
Modified papilla preservation
technique
Originally designed for use in
combination with self-supporting
barrier membranes.
Very effective and applicable in wider
wider than 2 mm at interdental tissue
level, especially in the anterior
dentition.

Surgical technique
Simplified papilla
preservation flap
To overcome some of the technical problems
encountered with the modified papilla preservation
technique, including difficult application in narrow
interdental spaces and in posterior areas and a
suturing technique not appropriate for use with non-
supportive barriers.
Interdental tissue
maintainence
Technique proposed by Murphy.
To be used in combination with nonresorbable barrier
membranes and grafting material. It involves the
reflection of a triangularly shaped palatal flap that
remains contiguous with the buccal portion of the flap.
Primary closure was obtained in 95% of the cases.
This technique can be applied only to defects located
in the upper jaw, preferably bicuspids, with an
interdental space wide at least 2 mm.

Wide defects (ample
radiographic angle) and/
or nonsupportive
anatomy (one- and two-
wall configurations)
Nonresorbable
barrier membranes – 1st
choice
Bioresorbable membranes
+ fillers
Narrow and/or supportive
defects
(3 wall configurations)
Indicate the use of
bioresorbable
barrier membranes.

The suturing approach is choosen according to :-
The defect anatomy and the type of membrane or combination material used in
a given case.
A combination of two sutures, one to relieve the tension, the other to close the
flap are mandatory.
A supportive defect (three-wall defect), a self-supporting membrane (titanium-
reinforced expanded polytetrafluoroethylene membrane) or a supported
membrane (combination therapy) requires suturing the interdental space with
an internal horizontal crossed mattress suture to relieve the tension.
If a nonsupported membrane (bioresorbable material) or a nonsupportive defect
(one- or two-wall defect) is the case, an offset internal mattress suture will be
chosen.
Primary closure of the interdental space will be attempted in both the
instances with a single passing suture when the papilla is very narrow; with two
parallel passing sutures when the papilla is wider; with an internal mattress
suture or with an internal mattress suture to get the best apposition of the flap
edges.

Massimo De Sanctis and Giovanni Zucchelli (2000) –
Treated forty deep (≥4 mm) interproximal angular bony
defects with presurgical clinical attachment loss of >8 mm were treated
by GTR using a non-absorbable expanded polytetrafluoroethylene
(ePTFE) membrane. Membranes were surgically removed 4 to 6 weeks
after surgery. Afterwards patients were placed on monthly recall for
the first year and every 3 months for the following 3 years. At the 4-
year re-evaluation, a IL-1 genetic susceptibility test was performed on
all patients.
The results of this study demonstrate that genotype
expression did not effect GTR treatment response at 1 year, but had a
great impact on long-term stability (year 4). In a 3-year period, patients
with positive IL-1 genotype lost about 50% of the first year gained CAL
and were about 10 times more likely of experiencing ≥2 mm CAL loss
when compared to oral hygiene matched genotype-negative patients.

As per the Guided Tissue Regeneration for the Treatment of
Periodontal Intrabony and Furcation Defects. A Systematic Review
(2003) results:-
 For the primary outcome variables, in both intrabony‐defect and
furcation‐defect studies, GTR was favored over open flap
debridement (OFD) therapies (P 0.0001).
 No differences were detected among barrier types, but barrier types
could explain some heterogeneity in the results.
 Augmentation of the GTR barrier with a particulate graft enhanced
vertical probing depth reduction (VPD) (P <0.05), vertical probing
attachment level (VPAL) gain, horizontal open probing attachment
level gain (HOPA), but none of the intrabony outcomes.
 Overall, GTR is consistently more effective than OFD in the gain of
clinical attachment and probing depth reduction in the treatment of
intrabony and furcation defects.

Ian Needleman (2005) – systematic review:
Eleven out of 16 studies showed greater attachment gain for
guided tissue regeneration than for open flap debridement.
However, this systematic review has shown that the outcomes
following GTR are highly variable both between and within studies.
Mitani A et al (2014) : - Retrospective study : 5 year clinical results
concluded, superior gains in clinical attachment level and
improved percentage bone fill can be obtained with EMD or GTR
when compared with OFD, and these can be maintained over a
period of 5 years.

Periodontal Regeneration – Intrabony Defects: A Systematic Review
From the AAP Regeneration Workshop (2015) concluded:-
1) Biologics (enamel matrix derivative and recombinant human
platelet‐derived growth factor‐BB plus β‐tricalcium phosphate) are
generally comparable with demineralized freeze‐dried bone
allograft and GTR and superior to open flap debridement
procedures in improving clinical parameters in the treatment of
intrabony defects.
2) Histologic evidence of regeneration has been demonstrated with
laser therapy; however, data are limited on clinical predictability
and effectiveness.
3) Clinical outcomes appear most appreciably influenced by patient
behaviors and surgical approach rather than by tooth and defect
characteristics.
4) Long‐term studies indicate that improvements in clinical
parameters are maintainable up to 10 years, even in severely
compromised teeth, consistent with a favorable/good long‐term
prognosis.

- Furcation
Primary objective:
complete elimination of
the furcation defect within
the interradicular space
Therapeutic end point
Realistic objective:
of reducing the magnitude
of the defect
Rarely achieved
and when
achieved, is
unpredictable.
Will be conversion of a class
III into class II, conversion of a
class II into a class I and the
attainment of significant
reductions in vertical and
horizontal attachment levels

General
factors
Oral
hygiene
Residual
periodontal
infection
Stress
Smoking
- Furcation

- Furcation
Relationship
between
furcation & root
trunk length
Residual osseous
morphology
Depth & width
of the intrabony
component of
the defect
Gingival
thickness
Root surface
preparation
Flap design
L
O
C
A
L
F
A
C
T
O
R
S

- Furcation
L
O
C
A
L
F
A
C
T
O
R
S
Selection & placement of membrane barrier
Placement of the membrane barrier
Post- operative care
Long term supportive therapy

-Mandibular grade II Furcation (related studies)

-Maxillary grade III Furcation (related studies)
R Pontoriero and J Lindhe (1995) - degree III maxillary furcation defects in
the 1st and/or 2nd molars were treated with ePTFE and re-evaluation after 6 months.
Re-entry results although showed some reduction in probing pocket depth and some
gain in probing attachment had occurred at both test and control sites, none of the
furcation defects had closed, but retained the characteristics of a degree-Ill furcation
involvement.
-Mandibular grade III Furcation (related studies)
Pontoriero et al.(1997)-
Stated that vertical bone loss of more than 3 mm will limit the success of
any attempt at GTR of mandibular molars with Class III furcations.
Thus, any Class III mandibular furcation with a vertical subclassification of
B or C would not be indicated for a GTR procedure

“Less favorable results are found in
mandibular and maxillary class III
defects and maxillary class II
defects, with GTR - as stated in the
literature review of Wang & Cooke
from 2005.”

Guided tissue regeneration in periodontal treatment:
- Gingival recession
Tinti C, Vincenzi G - Pioneers of
using GTR technique for treatment
of gingival recession
They introduced techniques for GTR to obtain root
coverage in an attempt to re-establish a connective
tissue attachment on exposed root surfaces.

Advantages
A reasonable
potential for true
regeneration of lost
periodontal
attachment
Absence of the
need for a second
surgical site
Disadvantages
More effort is
required to care for
the wound
postoperatively
Percentage of root
coverage not optimal
due to common
membrane exposure
and colonization of
oral microbiota on the
membrane

Danesh-Meyer and Wikesjö (2001) mentioned that –
GTR does not provide additional clinical beneﬁts over connective
tissue grafting or advanced ﬂap procedures in the treatment of gingival
recession. They proposed that the technical difficulties of GTR are
more hazardous than helpful for the clinician in controlling primary
wound closure, membrane exposure, space maintenance and
unacceptable foreign-body reactions. Furthermore, performing
connective tissue grafts over gingival recession defects results in
periodontal regeneration
Al-Hamdan K et al (2003) – Meta analysis of 40 papers : Inclusion
criteria – GTRC versus conventional mucogingival surgery (CMGS)
January 1990 to October 2001.
Results : Based on this meta-analysis, guided tissue regeneration-based
root coverage can be used successfully to repair gingival recession
defects. Conventional mucogingival surgery, however, resulted in
statistically better root coverage, width of keratinized gingiva, and
complete root coverage.

P Harinath et al (2008) ;Madhukant & Anand (2005);
Nandini Bhaskar et al (2013) :-
Study results concluded that coronally repositioned flap
combined with bilayer collagen membrane can be used for the
coverage of human gingival isolated buccal recession with
superior CAL gain on using collagen membrane.

“For multiple recession” – Healiguide + PRF
Kriti Agarwal, Chetan Chandra, Kanika Agarwal,Nishant Kumar JISP Vol 17, Issue 6, Nov-Dec 2013

COMPLICATIONS ASSOCIATED WITH GTR MEMBRANES
IN EARLIER TIMES
Membrane
exposure
Contamination of exposed
nonresorbable and resorbable
barrier membranes has been
associated with reduced probing
attachment gains in intrabony
defects
Post operative
complications
Swelling & suppuration
Erythema &
postoperative pain
Membrane exfoliation
Sloughing/ necrosis or
perforation of the flap

COMPLICATIONS ASSOCIATED WITH GTR MEMBRANES
IN EARLY TIMES
“Pseudo pocket formation” Exophytic tissue formation
Membrane exposure
Murphy et al (1995) retrospective study – 102 sites in 62 patients
examined frequency of complications

Trends in GTR membrane development
Growth and differentiation factors + GTR –
-Yoon Jeong Park (1997) - PDGF-BB loaded membrane
markedly increased new bone formation in rat calvarial
defects, and completed bony reunion after 2 weeks of
implantation period. These results suggested that PDGF-BB
loaded porous poly (L-lactide) PLLA membrane might
potentially enhance guided tissue regenerative efficacy.
-Talal A, McKay IJ, Tanner KE, Hughes FJ (2013) - The use of a
nHA-PLA composite material containing a high concentration
of nHA may be a useful material for GTR membrane as it will
not only act as a barrier, but may also be able to enhance
bone regeneration by delivery of biologically active
molecules like PDGF.

Trends with GTR membranes
GTR + Antibiotics
-The incorporation of metronidazole benzoate (MET) to the layer interfacing the
epithelial tissue has been developed to reduce the amount of anaerobic Gram-
negative bacteria such as Porphyromonas gingivalis and anaerobic spore-forming
Gram-positive bacilli (Freeman CD, Klutman NE, Lamp KC (1997); El-Kamel AH
(2007) ; Bottino MC (2011).
-TCH was incorporated into poly(l-lactic acid) (PLLA) fibers either via blending or
coaxial e-spinning . Two relevant conclusions were drawn based on the in vitro
drug release evaluation. First, it was demonstrated that threads processed from
the core–shell fibers had a lower early burst and a more continuous release.
Second, the threads processed from the blend fibers resulted in a greater early
burst release, which can be of great value in avoiding bacterial infection (He CL,
Huang ZM, Han XJ 2009).
-Chen YT et al (2003) - An expanded polytetrafluoroethylene (ePTFE) membrane,
glycolide fiber membrane, and collagen membrane were loaded with
chlorhexidine and characterized . Chlorhexidine released from the coated GTR
membranes inhibited the growth of A. actinomycetemcomitans.

Development of a new series of electrospun nanoparticles-in-nanofibrous
scaffolds for GTR/GBR applications with enhanced antibacterial and bone
regeneration activity (Dina Abdelaziz, Amr Hefnawy, Essam Al-Wakeel, Abeer El-
Fallal, Ibrahim M. El-Sherbiny 2021)

Conclusion
- Conventional methods, aimed at the regeneration of lost
periodontal tissue support, have mainly focused on bone
regeneration. This is evidenced by the large number of reports
presented in the literature on the results of therapy using various
kinds of graft materials in periodontal defects.
- The use of different types of bone grafts or bone substitutes to
accomplish periodontal tissue regeneration can be considered to be
founded on an incorrect biological basis, since bone does not
possess the ability to regenerate lost connective tissue attachment .
- Guided periodontal tissue regeneration is a well-documented and
accepted therapeutic modality to facilitate periodontal
regeneration.
-The use of GTR membranes can lead to formation of cementum
with inserting fibers. Hence, the use of GTR barrier membranes
should form the part of the armamentarium for treating
periodontitis.

References
-Clinical periodontology and implant dentistry
Jan Lindhe 5th edition
- Membranes for Periodontal Regeneration
Andrej Aurer Ksenija JorgiE-Srdjak
Acta Stomatol Croat, Vol. 39, br. 1, 2005.
-IL- 1 gene polymorphism s and long-term stablility following GTR
therapy.
Massimo De Sanctis and Giovanni Zucchelli
J Periodontol 2000; 71: 606-613.
-Degradation of collagen-guided tissue regeneration membranes by
proteolytic enzymes of Porphyromonas gingivalis and its inhibition
by antibacterial agents.
Michael N. Sela, Eleonora Babitski., Doron Steinberg, David Kohavi
Graciela Rosen.
Clin. Oral Impl. Res. 20, 2009 / 496–502.

Recent advances in the development of GTR/GBR membranes
for periodontal regeneration—A materials perspective.
Marco C. Bottinoa et al
Dental materials 28 (2012) 703–721.
- GTR membranes : The barriers for periodontal regeneration
Awadhesh K. Singh
DHR International Journal Of Medical Sciences (DHR-IJMS)
Vol. 4(1), 2013.
-Biocompatibility and cytotoxic evaluation of drug-loaded
biodegradable GTR membranes.
Thomas NG et al
Journal of Indian Society of Periodontology Oct- Dec 2012,
Vol16, Issue 4.
References

Treatment of the gingival recession ── literature review of current
progress Lein-Tuan Hou et al Chin Dent J 2005‧Vol 24‧No 2.
Evaluation of treatment techniques for advanced (grade ii – iv)
furcation defects. a literature review of the regenerative methods
Adrian-George Marinescu et al TMJ 2011,Vol. 61,No.1 -2.
Current status of guided periodontal tissue regeneration
Carlosr.Quinones & Raul. G.Caffess . Periodontology 2000, Vol. 9,
1995, 5568.
Richard T. Kao, Salvador Nares, Mark A. Reynolds. Periodontal
Regeneration – Intrabony Defects: A Systematic Review From the AAP
Regeneration Workshop. J Periodontol 2015;86(25):S77-S104.
Kevin G Murphy, John C Gunsolley. Guided tissue regeneration for the
treatment of periodontal intrabony and furcation defects. A
systematic review. Ann Periodontol. 2003 Dec;8(1):266-302.
e
References

References
- Focus on furcation defects: guided tissue regeneration.
Mariano Sanz & Jean Louis Giovannoli. Periodontology 2000, Vol. 22,
2000, 169–189.
- Focus on intrabony defects: guided tissue regeneration
Pierpaolo Cortellini & Maurizio S. Tonetti Periodontology 2000, Vol. 22,
2000, 104–132.
-Development of the biological concept of guided tissue regeneration -
animal and human studies. THORKILKDA RRING,S TUREN YMANJ, AN
GOTTLOW& LARSL AURELL .Periodontology 2000, Vol. 1, 1993,26-35
-Eun Jin Kim et al. Preparation of biodegradable PLA/PLGA membranes
with PGA mesh and their application for periodontal guided tissue
regeneration. 2009 Biomed. Mater. 4 055001

References
-Dina Abdelaziz, Amr Hefnawy, Essam Al-Wakeel, Abeer El-Fallal, Ibrahim
M. El-Sherbiny New biodegradable nanoparticles-in-nanofibers based
membranes for guided periodontal tissue and bone regeneration with
enhanced antibacterial activity. Journal of Advanced Research 2021;28:51-
62.
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references section).

Guided tissue regeneration

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