Guided tissue regeneration (GTR) is a technique used in periodontal therapy to regenerate lost periodontal tissues by placing a barrier membrane over periodontal defects. The membrane prevents epithelial and gingival connective tissue cells from repopulating the root surface, allowing periodontal ligament cells to repopulate and regenerate cementum, bone, and periodontal ligament. Classic studies in the 1980s proved that only periodontal ligament cells have the potential for regeneration of periodontal structures. Clinical application of GTR involves placing a physical barrier membrane during periodontal flap surgery to isolate the root surface and allow repopulation with periodontal ligament cells. Membranes can be resorbable or non-resorbable

1. Guided Tissue Regeneration
DR. ABDULLAH KARAMAT

2. 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 Terms 1992)

3. Guided Tissue Regeneration: The method for
the prevention of epithelial migration along
the cemental wall of the pocket and
maintaining space for clot stabilization is a
technique called guided tissue regeneration
(GTR). GTR Procedures allowing the
repopulation of a periodontal defect by cells
capable of forming new connective tissue
attachment and alveolar bone.

4. Melcher 1976 - Following
flap surgery, the curetted
root surface
may be repopulated by (1)
epithelial cells, (2) gingival
connective tissue cells, (3)
bone cells, or (4) periodontal
ligament cells.

5. Nyman(1982) , Gotlow(1984), Karring (1986)
did classic studies and proved that only the
periodontal cells have the potential for
regeneration of the apparatus of the tooth

6. Clinical application of GTR
Clinical application of guided tissue regeneration (
GTR) in periodontal therapy involves the
placement of a physical barrier to ensure that the
previous periodontitis affected root surface
becomes repopulated with cells from the
periodontal ligament.
Treatment of the first human tooth with GTR was
reported by Nyman et al. in 1982. Due to
extensive

7. periodontal destruction, the tooth was
scheduled for extraction. This offered the
possibility of obtaining histological
documentation of the result of the treatment.
Following elevation of full thickness flaps,
scaling of the root surface and removal of all
granulation tissue, an11 mm deep periodontal
lesion was ascertained. Prior to flap closure, a
membrane was adjusted to cover parts of the
detached root surfaces, the osseous defect
and parts of the surrounding bone.

8. Histological analysis after 3 months of healing
revealed that new cementum with inserting
collagen fibers had formed on the previously
exposed root surface .
In a later study (Gottlow et al. 1986), 12 cases
treated with GTR were evaluated clinically,
and in five of these cases histologic
documentation was also presented. The
results showed that considerable but varying
amounts of new connective tissue attachment
had formed on the treated teeth.

10. Barrier membranes:
There are five criteria which are considered to
be important in the design of barrier
membranes used for GTR ( Greenstein &
Caton 1993). These include : biocompatibility ,
cell occlusiveness , spacemaking , tissue
integration and clinical manageablilty

11. 1- Non resorbable
A. e-PTFE
B. d-PTFE
C. Millipore and Nucleopore
D. Silicone barriers
Types of membranes :

12. 2- Resorbable membranes
A. Synthetic
I. Polylactide
II. Polyglycolic acid
III. Vicryl mesh
IV. Cargile membrane
B. Natural : Collagen membrane

13. Current trends in membranes :
• Membranes containing metronidazole
• Membranes combined with growth factors like
PDGF and BMPs
• Combined use with Enamel Derived Proteins
(EMDOGAIN)

14. Indications
1. Class II furcation
2. Infra bony defect.
3. Recession defect (class 1 and 2 )
4. To restore PD attachement in narrow 2 or 3
walled infra bony defect.
5. Alveolar ridge augmentation
6. Repair of apicocetomy defect.

15. Contra indications:
1. In cases where flap vascularity will be
compromised.
2. Very severe defect-minimal remaining
periodontium.
3. Horizontal defects.
4. In cases of flap perforation.

16. Procedure:
Surgery is initiated by sulcular or marginal
incisions at both the buccal and lingual aspect
of the jaw, followed by buccal and vertical
releasing incisions. The releasing incisions
must be placed a minimum of one tooth
anterior and/or posterior to the tooth that is
being treated

17. Following marginal incisions and vertical releasing
incisions on the buccal aspect of the jaw, buccal
and lingual full thickness flaps are elevated.

18. Care should be taken during this procedure to
preserve the interdental papillae. All pocket
epithelium is excised so that a fresh
connective tissue is left on the full thickness
flaps following reflection. After elevation of
the tissue flaps, all granulation tissue is
removed and thorough debridement of the
detached root surfaces is carried out using
curettes, burs, etc.

19. Various types of bioabsorbable and non-
bioabsorbable barrier materials are available in a
variety of configurations designed for specific
applications. The configuration most suitable for
covering the defect is selected and additional
tailoring of the material is performed. The
shaping of the material is carried out in such a
way that it is adapting closely to the tooth and is
completely covering the defect, extending at least
3 mm on the bone beyond the defect margins
after placement

20. The barrier material is placed in such a way
that it completely covers the defect and extends at least 3
mm on the bone beyond the defect margin.

21. For optimal performance, the barrier should
be placed with its margin 2-3 mm apically to
the flap margin. To maximize coverage of the
barrier, a horizontal releasing incision in the
periosteum may assist in the coronal
displacement of the flap at the suturing of the
wound

22. The elevated tissue flaps are coronally displaced
and sutured in such a way that the border of
the barrier material is at least 2 mm below the flap margin.

23. Post op :
To reduce the risk of infection and to assure
optimal healing, the patient should be instructed
to gently brush the area postoperatively with a
soft bristle toothbrush and to rinse with
chlorhexidine (0.2%) for a period of 4-6 weeks. In
addition, systemic antibiotics are frequently
administered immediately prior to surgery and
during 1-2 weeks after surgery. When a non-
bioabsorbable barrier is used, it should be
removed after 4-6 weeks. However, if
complications develop it may be necessary to
remove it earlier.

24. References
• Jan Lindhe(2008). Textbook of Clinical Periodontology and Implant Dentistry,
4th edition
• Carranza’s Clinic Periodontology 11th edition
• J D Manson & B M Eley – Periodontics, Fourth Edition
• Melcher AH (May 1976). "On the repair potential of periodontal tissues". J.
Periodontol. 47 (5): 256–60.
• Nyman S, Lindhe J, Karring T, Rylander H (July 1982). "New attachment
following surgical treatment of human periodontal disease". J. Clin.
Periodontology
• Gottlow J, Nyman S, Karring T, Lindhe J (September 1984). "New attachment
formation as the result of controlled tissue regeneration". J. Clin. Periodontol.
• Gottlow J, Nyman S, Lindhe J, Karring T, Wennström J (July 1986). "New
attachment formation in the human periodontium by guided tissue
regeneration. Case reports". J. Clin. Periodontol.

25. “All things are subject to
interpretation. Whichever
interpretation prevails at a given
time is a function of power and not
truth.”
Friedrich Nietzsche