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Guided Tissue regeneration and Guided Bone Regeneration
Guided Tissue Regeneration (GTR) is a method for
prevention of epithelial migration along the cemental wall
of the pocket.
Guided Bone Regeneration (GBR) is a procedure in
which a membrane is placed over the bone defect site.
This membrane encourages new bone to grow and also
prevents the in-growth of fibrous scar tissue into the
grafted site.
PRINCIPLE:
Assumption that only periodontal ligament cells have the
potential for regeneration of the attachment apparatus of
the tooth.
Exclusion of faster growing epithelium and connective
tissue from the periodontal wound fro 6 to 8 weeks allows
the slower growing tissues to occupy the space adjacent
to the tooth.
GTR
The periodontal ligament cells and the cementoblasts are
allowed to proliferate.
GBR
The osteoblasts are allowed to proliferate.
GUIDED TISSUE REGENERATION
INDICATION OF GTR
*Class II Furcation lesion In Mandibular Molars And
Interproximal Defects.
*Peripheral Inflammatory Root Resorption – after surgical
removal of granulation tissue.
*Treatment of periodontal pockets.
*Recession-type defects
*For pre-implant and peri-implant surgery
IDEAL PROPERTIES OF THE MEMBRANE:
1. Biocompatible
2. Space maintenance
3. Cell occlusiveness
4. Good handling properties
5. Resorbablity
TYPES
Non Resorbable :
Milipore
polytetrafluoroethylene ( Gore-Tex , Gore-Tex periodontal
membrane)
expanded polytetrafluoroethylene
Resorbable :
rat , bovine, porcine collagen
cargile membrane - cecum of ox, polylactic acid
Vicryl ( polyglactin 910)
Biobrane
OsseoQuest – polyglycolic acid, polylactic acid, trimethylene
carbonate – 6 – 14 months
BioGuide- bilayer porcine derived collagen
Atrisob- polylactic acid gel
BioMend- bovine Achilles tendon collagen – 4 to 18 weeks
Non - Resorbable membrane:
Advantage:
* Has the ability to maintain separation of tissues over an
extended period of time.
Disadvantage:
•Require a second procedure to remove It, usually 3 to 6 weeks.
* Early removal result in less bone regenration.
*If it is exposed , will not heal spontaneously – can become
contaminated with oral bacteria – infection-result in bone loss.
Resorbable Membranes
Advantage:
*Elimination of surgical re entry for the
membrane removal.
Disadvantage:
*They can degrade before the bone formation is complete
*Degradation process is associated with various degree of
inflammation.
*They are quite pliable- collapse of membrane into the defect
area.
PROCEDURE:
Raise the mucoperiosteal flap – minimum 2 teeth anteriorly, one
tooth distally
Debride the osseous defect and thoroughly plane the roots
Trim the membrane with sharp scissors to the approximate size. The
borders of the membrane should extend 3-4mm apical to the margin
of the defect,2-3mm laterally beyond the defect, occlusally 2mm
apical to cemento enamel junction.
Suture the membrane tightly around the tooth – sling suture
Suture the flap back in its original position. The flap should cover the
membrane completely.
Periodontal dressing maybe used. Antibiotic treatment is given to the
patient for one week.
After 4 -6 weeks – margin of membrane is exposed. The
membrane is removed with a gentle tug. If it cannot be removed –
tissues are anaesthetized, and the material is removed surgically
using a mini flap.
GTR IN POCKET THERAPY
21 with 10 mm pocket
depth and 11mm CAL. A
midline diastema is present.
Full thickness buccal and
palatal flaps have been
raised and an intra bony
defect can be seen.
Modified Papilla
Preservation Technique
A Ti reinforced e-PTFE
barrier membrane has been
placed and fixed close to
the level of the CEJ.
The membrane is completely
covered. Primary closure has
been obtained by preserving
the interdental papilla and by
the coronal displacement of
the buccal tissue flap.
At 6 weeks the membrane is
completely covered by
healthy tissue.
After membrane removal at
6 weeks , dense newly
formed tissue is evident in
the defect and in the supra
crestal space maintained by
the Ti – reinforced
membrane
The newly formed tissue is
completely covered by the
raised and well preserved
tissue flaps
The photograph after 1 year
shows a 4 mm residual pocket
depth. A gain of clinical
attachment of 6mm was
recorded and no recession has
occurred compared to the
baseline.
Recession Coverage using GTR
GTR Case 2
Guided tissue regeneration (GTR) using a membrane and bone graft.
Initial probing pocket depth: 11+ mm
Final probing pocket depth: 4 mm at 10 months post-op
Surgery by : Dr. Ricardo Diaz
GTR Case 3
Guided tissue regeneration (GTR) using a membrane and bone graft.
Beginning probing pocket depth: 12+mm
Final pocket probing depth: 4 mm at 12 months post-op
Surgery by : Dr. Eduardo Lorenzana
ORTHODONTICS AND GTR
In theory GTR is advantageous in orthodontic treatment for
•Extrusion and Intrusion of teeth wit infra bony defect
•Uprighting of tipped molars with mesioangular lesion
•Pre orthodontic GTR can prevent the epithelium migrating apically
and a bodily tooth movement into or through an intra bony defect can
eliminate the bony pocket more easily./
GUIDED BONE REGENERATION
In the GBR technique, a barrier membrane is placed over the
periodontal defect to prevent the in-growth of cells from the
gingival connective tissue, epithelium, and the periodontal
ligament.
INDICATION FOR GBR
Periodontal
defect
Defects Around
Dental Implants
Defects Following
Cyst or Tumor
Surgery
Insufficient Amount of
Jaw Bone to Support
Dentures or Bridges
Defects
Following Tooth
Extraction
MATERIALS USED FOR GBR:
Barrier Membrane:
Resorbable
Copolymers of polylactide and polyglycolide
Collagen
Non resorbabale
Latex
Teflon (ePTFE)
Titanium reinforced membrane – don’t need bone grafts for
regenerating bone.
Bone grafts:
Autografts
Allografts
Undecalcified freeze Dried Bone Allograft
Decalcified Freeze Dried Bone Allograft
Xenografts
Boplant – calf bone
Kiel Bone (calf or ox bone)
Anorganic Bone – from ox
Bio Oss ( Osteo health) – anorganic bovine derived bone
They help in maintaining space under the barrier membrane
to facilitate the formation of bone within a confined space.
Requirement of Bone graft.
They should facilitate the ingrowth of neo vascularisation
and migration of osteoblasts.
BIOLOGICAL MECHANISMS OF BONE GRAFT MATERIALS
Osteoconduction – formation of bone by osteoblasts from the margins
of the defect on the bone graft material. Osteoconductive materials
serve as scaffold for bone growth.
Osteoinduction- new bone formation through the stimulation of
osteoprogenitors from the defect to differentiate in to osteoblasts and
begin new bone formation.
Osteogenesis- occurs when living osteoblasts are part of the bone
graft , as in autogenous transplantation.
The following is one example of these procedures following tooth
extraction.
1. The tooth is removed and the
remaining tooth socket is
thoroughly cleaned of all
inflamed and infected tissue.
3. GBR membrane (eg. BioGide®) is often placed over the
grafted material to protect the
newly growing bone.
2. An appropriate bone grafting
material (eg. Bio-Oss®) is carefully
placed into the extraction socket.
4. Sutures placed into the gum allow
proper healing of the surrounding soft
tissue.
GBR Case
Guided bone regeneration (GBR) using a biocompatible membrane and an
autogenous bone graft mixed with deproteinized bovine bone mineral
(Bio-Oss®).
Figure 1: Careful flap reflection reveals a narrow ridge (3-4 mm wide),
preventing implant placement at this time.
Figure 2: Seven months after the augmentation procedure, there is
approximately 8 mm of ridge width available for implant placement.
Figure 3: A wide-diameter (5 mm wide x 10 mm long) implant was placed.
FACTORS INFLUENCING REGENERATION
Patient factors:
Smoking
Stress
Diabetes mellitus
Other systemic conditions
Presence of deep multiple pockets
Local factors:
Furcal anatomy
Thickness of gingival tissue
Surgical factors:
Infection control,
Bone replacement grafts combined with barriers or GTR alone,
Type of barrier and surgical technique
Postoperative factors:
Plaque control
Membrane exposure
Membrane retrieval
Regular supportive periodontal care program
REFERENCES:
Clinical Periodontology & Implant Dentistry by Jan Linde
– 3rd edition
Clinical Periodontology by Carranza – 10th edition
Internet Sources:
Jcdp.com
Osteohealth.com
Advancedperiodontics.com
Ridental.com
Periodont.com
Scielo.br