|Year : 2021 | Volume
| Issue : 1 | Page : 46-49
Guided tissue regeneration
Shreeprasad Vijay Wagle, Amit Arvind Agrawal, Dinaz Bardoliwala, Chhaya Patil
Department of Periodontology and Implantology, MGV's KBH Dental College and Hospital, Nashik, Maharashtra, India
|Date of Submission||14-Apr-2020|
|Date of Decision||20-Jun-2020|
|Date of Acceptance||31-Jul-2020|
|Date of Web Publication||15-Feb-2021|
Shreeprasad Vijay Wagle
Department of Periodontology and Implantology, MGV's KBH Dental College and Hospital, Nashik, Maharashtra,
Source of Support: None, Conflict of Interest: None
Regeneration is 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. Epithelium acts as a barrier to successful therapy because its presence interferes with the direct apposition of connective tissue and cementum, therefore would limit the height to which periodontal fibers can become inserted to cementum. Guided tissue regeneration (GTR) describes procedures attempting to regenerate lost periodontal structures through differential tissue responses and typically refers to regeneration of periodontal attachment. Barrier techniques are used for excluding connective tissue and gingiva from the root in the belief that they interfere with regeneration.
Keywords: Guided tissue regeneration, periodontitis, vertical bone defect
|How to cite this article:|
Wagle SV, Agrawal AA, Bardoliwala D, Patil C. Guided tissue regeneration. J Oral Res Rev 2021;13:46-9
| Introduction|| |
The regeneration or restitution of lost supporting tissue has always been considered the ideal objective of periodontal therapy. Regeneration can be defined as the reproduction or reformation of organs or tissue that has been lost or injured as a result of a wound or infection. Regenerative periodontal procedure involves the creation of new alveolar bone, cementum, and periodontal ligament. Most periodontal practices focus on the prevention of disease, initiation, and corrective surgical treatment to eliminate deep pockets. Regeneration is distinct from tissue repair and is characterized by replacement of the damaged tissues with something that may be inferior to the original tissues, both structurally and functionally.
Eliminating bacteria and regenerating bone and supporting tissues helps in reducing pocket depth and repair damage caused by the progression of periodontal disease. Over the last decade, different modalities of regenerative treatment have been used and clinically applied. The positive effect of bone grafts and bone substitute on the outcome of periodontal regenerative procedures is well documented. Bone substitute should have the following properties such as clinical effectiveness, functional periodontal repair, apparent bone defect fill, and pocket reduction to manageable levels.
Infrabony defects are a common clinical finding in periodontal disease. Multiple treatment options are available for treating infrabony defects – (i) conventional flap surgery, (ii) resective osseous surgery, (iii) regenerative osseous surgery, (iv) bone grafts, (v) guided tissue regeneration (GTR), and (vi) platelet-rich plasma. GTR in a combination of various grafts has shown promising effect in improving clinical and radiographic parameters.
The main objective of GTR is to regenerate the periodontal tissues lost due to advanced stages of disease. The principle of GTR is allowing selective repopulation of periodontal cells, especially fibroblasts, which helps in the formation of new periodontal tissues. In addition, the membrane provides space for optimal wound stability that is necessary for periodontal regeneration.
| Case Report|| |
A 36-year-old male patient reported with generalized gingival bleeding and difficulty in chewing related with mandibular right posterior teeth. The clinical presentation included a reddish pink, swollen gingiva, with bleeding on probing and clinical probing depth in the mandibular right [Figure 1]a posterior quadrant recorded between 6 and 9 mm, while in the remaining areas, it ranged between 3 and 5 mm. Horizontal defects were found radiographically and a vertical defect was found with respect to the mandibular right molars, Grade III furcation involvement with 46 suggestive of generalized aggressive periodontitis [Figure 1]b. Therapeutic scaling and root planing (SRP) was performed, and curettage was done. The management for the mandibular right posteriors further included a conventional flap surgery with demineralized freeze-dried bone allograft (DFDBA) bone graft and collagen membrane placement for bone regeneration with respect to tooth numbers 46 and 47 [Figure 2].
|Figure 1: (a) Preoperative probing depth. (b) Preoperative orthopantomogram showing vertical and horizontal bone loss|
Click here to view
|Figure 2: Intraoperative and immediate postoperative views. (a) Bone graft placed and collagen membrane applied, (b) interrupted loop suturing done using 3-0 silk suture|
Click here to view
A thorough Phase I therapy was done to reduce the inflammation. Root canal treatment was performed 2 months prior to surgery. The patient was given antibiotics and analgesics for 3 days (amoxicillin 500 mg thrice daily, paracetamol and aceclofenac combination twice daily, and pantoprazole 40 mg twice daily) and asked to report after 1 week after SRP for surgery. Prior to surgery, again the probing depth was measured. The pocket depth was 9 mm with tooth number 46 on the day of surgery. Local anesthesia was achieved by buccal and lingual infiltration. Lignocaine hydrochloride with adrenaline (1:80,000) was used. Full-thickness mucoperiosteal flap was elevated both buccally and lingually. Granulation tissue was removed using a curette (Hu-Friedy, USA). Calculus deposits were removed with ultrasonic scaling. The inflamed inner wall of the flap was trimmed using Castro-Viejo scissors [Figure 3].
|Figure 3: Pre-and intra-operative photographs of surgical site. (a) Probing depth, (b) combined osseous defect and furcation involvement seen after periodontal flap reflection and debridement, (c) vertical bone defect measurement at distobuccal line angle with 46, (d) vertical bone defect measurement at mesiobuccal line angle with 46|
Click here to view
DFDBA bone graft was mixed with saline to a packable consistency. The bone graft was packed into the site in increments using a condenser. The bone graft was filled adequately and condensed. Care was taken to avoid overfilling the defect. The collagen membrane was cut according to the size of the defect. The membrane was then inserted into the defect and presuturing was done before complete placement of the membrane. The membrane was inserted totally into the defect and the final knot was placed [Figure 2].
Suture removal was done after 1 week. The patient did not develop any postoperative complications. The wound healing was satisfactory after 1 week of surgery. Saline irrigation was done to remove soft deposits and sutures were removed. The patient was recalled after every 3 months, and then clinical parameters were assessed clinically as well as radiographically. The probing depth was not assessed in order to avoid any injury to the healing tissues. Intraoral periapical radiograph after 6 months showed an appreciable increase in bone level and bone fill [Figure 4].
|Figure 4: (a) Intraoral periapical radiographs before periodontal therapy, (b) intraoral periapical radiographs after 6 months of regenerative periodontal therapy showing bone fill in defect with tooth number 46|
Click here to view
| Discussion|| |
A prominent clinical finding in advanced periodontal disease cases is infrabony defects. Numerous regenerative techniques have been developed to treat such defects with varying clinical results. GTR in combination with bone graft stands as a successful treatment modality in periodontal regenerative surgeries. GTR is found to be more effective when compared with conventional surgery in the gain of clinical attachment, reduction in probing depth, and in the treatment of intrabony and furcation defects.
DFDBA was used as a bone graft substitute in this case. The principal reason behind demineralizing is based on studies by Urist <Italic>et al</Italic>., who suggested that the demineralization of lyophilized bone would allow the exposure of morphogenetic bone proteins and polypeptides that induce the pluripotential stem cells to differentiate into osteoblasts. However, it has been found that this osteoinductive capacity depends on the donor characteristics, especially the age, and the degree of demineralization, in such a way that depending on the bone bank and even the batch, the capacity to induce bone formation can vary and may even be nonexistent.
Numerous studies support the use of the bone graft material and the collagen membrane used in this case. The bone graft occupies the infrabony defect as a filler material., It helps in supporting the GTR membrane by preventing the collapse. It acts as a substitute for the lost bone and facilitates native bone formation. This process of formation of native bone is done by osteoconductive/osteoinductive activity. It enhances the process of healing following surgery. It serves as a framework to the bone-forming cells and blood vessels, thereby encouraging formation of healthy new bone and also helping in the repair of the osseous defect.
Collagen membrane is a bio-absorbable membrane. It undergoes resorption by getting incorporated into the connective tissues or by undergoing degradation by macrophages. This process takes about 6–8 weeks to complete. Even though they undergo resorption, their function in acting as a barrier is as effective as a nonresorbable membrane.
The collagen membrane acts as a scaffold upon which the fibroblasts migrate and undergo proliferation to form the periodontal ligament fiber cells. The Type I collagen contained in membrane also has hemostatic property. This property enables the membrane to accelerate the wound healing in the surgical site, thereby yielding faster results.,
In the present study, after 3 months of surgery, probing pocket depth was reduced to 4 mm and the clinical attachment loss was reduced from 9 to 5 mm distal to 36. The bone fill of about 4 mm was observed in the intrabony defect with 36 [Figure 4].
| Conclusion|| |
The results of this case study indicate that the use of GTR technique (collagen membrane) in combination with DFDBA bone graft material was beneficial for the treatment of periodontal intrabony defects. This combination technique provided improved outcomes in terms of clinical and radiographic parameters.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Karring T, Nyman S, Gottlow J, Laurell L. Development of the biological concept of guided tissue regeneration – Animal and human studies. Periodontol 2000 1993;1:26-35.
Murphy KG, Gunsolley JC. Guided tissue regeneration for the treatment of periodontal intrabony and furcation defects. A systematic review. Ann Periodontol 2003;8:266-302.
Joly JC, Palioto DB, de Lima AF, Mota LF, Caffesse R. Clinical and radiographic evaluation of periodontal intrabony defects treated with guided tissue regeneration. A pilot study. J Periodontol 2002;73:353-9.
Elkhatat EI, Elkhatat AE, Azzeghaiby SN, Tarakji B, Beshr K, Mossa H. Clinical and radiographic evaluation of periodontal intrabony defects by open flap surgery alone or in combination with Biocollagen®
membrane: A randomized clinical trial. J Int Soc Prev Community Dent 2015;5:190-8.
Keles GC, Sumer M, Cetinkaya BO, Tutkun F, Simsek SB. Effect of autogenous cortical bone grafting in conjunction with guided tissue regeneration in the treatment of intraosseous periodontal defects. Eur J Dent 2010;4:403-11.
Urist MR, Sato K, Brownell AG, Malinin TI, Lietze A, Huo YK, <Italic>et al.</Italic> Human bone morphogenetic protein (hBMP). Proc Soc Exp Biol Med. 1983;173:194-9.
Needleman I, Worthington HV, Giedrys-Leeper E, Tucker R. Guided tissue regeneration for periodontal infra-bony defects. Cochrane Database of Systematic Reviews 2006.
Nanditha S, Priya MS, Sabitha S, Arun KV, Avaneendra T. Clinical evaluation of the efficacy of a GTR membrane (HEALIGUIDE) and demineralised bone matrix (OSSEOGRAFT) as a space maintainer in the treatment of Miller's Class I gingival recession. J Indian Soc Periodontol 2011;15:156-60.
] [Full text]
Chandradas ND, Ravindra S, Rangaraju VM, Jain S, Dasappa S. Efficacy of platelet rich fibrin in the treatment of human intrabony defects with or without bone graft: A randomized controlled trial. J Int Soc Prev Community Dent 2016;6:S153-9.
Jain D, Deepa D. A comparative evaluation of freeze-dried bone allograft with and without bioabsorbable guided tissue regeneration membrane Healiguide(®
) in the treatment of Grade II furcation defects: A clinical study. J Indian Soc Periodontol 2015;19:645-50.
] [Full text]
Prasanna JS, Karunakar P, Rajashree D, Solomon RV. Bone regeneration in a periodontally challenged hopeless tooth. J Dr NTR Univ Health Sci 2013;2:296.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]