GUIDED TISSUE

REGENERATION
 DEFINITION
• REGENERATION:- Regeneration is the
growth & differentiation of new cells &
intercellular substances to form new tissues or
parts.

• GUIDED TISSUE REGENERATION:- The

method for the prevention of epithelial
migration along the cemental wall of the
pocket that has gained wide attention & called
GTR.
 INTRODUCTION
• This method based on the
assumption that only the
periodontal ligament cells have
the potential for the
regeneration of the attachment
appratus of tooth.

• It consists of placing barriers

of different types to cover the
bone & periodontal ligament
thus temporarily separating
them from gingival epithelium.
• Excluding the epithelium & the gingival
connective tissue from the root surface
during the post surgical healing phase not
only prevent epithelial migration into the
wound but also favours repopulation of
the area by cells from the periodontal
ligaments & the bones.
ANIMAL STUDIES
• A number of studies were undertaken to
determine the nature & quality of the
attachement when the root surface was
repopulated by different selected cell types.

• NYMAN et al (1982) used a millipore filter

over a window created in the bone & found
that only when cells from the PDL were allow
to repopulate the wound was total
regeneration achieve.
• GOTTLOW et al (1984) used both a millipore
filter & a Gore Tex membrane over
submerged roots in monkeys to demonstrate
repopulation of the wound by cells of PDL
resulting in a considerably greater increase
in new attachment of test teeth.

• KARRING et al (1986) used a combination of

tight & loose elastic about the roots to
prevent or permit cell repopulation from the
PDL.
HUMAN STUDIES

• NYMAN etal (1982) tested the

hypothesis of GTR on a single
mandibular incisor using a millipore
filter. He was able histologically to
show 5 mm. of new attachment above
the alveolar crest 3 months later.
• The use of polytetrafluoroethylene
membrane.(Gore Tex PD material) has
been tested in controlled clinical studies
in lower molar furcations & has shown
statistically significant decrease in
pocket depth & involvement in
attachment level after 6 month.
 BARRIERS
1.NONBIORESORBABLE MEMBRANE:-

It is biocompatible porous material possessing two

unique microstructures.

• One is the open microstructure of its collar, which

is design to retard or inhibit the apical
proliferation of epithelium through contact
inhibition.
• The other is occlusive
membrane which acts as
a barrier to the gingival
connective tissue & the
underlying root surface.

•Different shapes & size

of expanded PTFEa
membrane are available.
 NON BIORESORBABLE
MEMBRANE

1.e-PTFE :-Titanium
:- reinforced expanded
polytetrafluoroethylene membrane.
2.Nucleopore & Millipore filters.
3. Silicon Barriers
4. Sterlized rubber dam.
 2. BIO RESORBABLE
MEMBRANE
• Composed of polylactic acid bonded with a
citric acid ester.
• It is design to provide initial barrier
function during the early stages of healing
(minimum of 6 wk), & during later stages the
barrier is slowly resorbed & replaced by the
periodontal tissue underlying root surface
 BIORESORBABLE
MEMBRANE

1. Collagen (Periogen, Biomend)

2. Polylactic acid & Polyglycolic acid
polymer.
(Guidor, Vicryl, Atrisorb, Resolut,
Epiguide)
 GOTTLOW’S
CLASSIFICATION
• First generation (Nonresorbable)
• Second generation (Resorbable)
• Third generation
(Resorbable with growth factor)
 FIRST GENERATION
MEMBRANES

1. Millipore Filter
2. Expanded polytetrafluoroethylene
membrane (e-PTFE)
3. Nucleopore membrane.
4. Rubber Dam.
 SECOND GENERATION
MEMBRANE
1. Collagen Membrane.
2. Polylactic acid Membrane. (Guidor)
3. Vicryl Mesh
4. Cargile Membrane.
5. Oxidised Cellulose Membrane
6. Hydrolyzable polyester.
 THIRD GENERATION
MEMBRANE

• They are the Bio-resorbable membrane

with added growth factor.
 NON RESORBABLE
MEMBRANE ARE AVAILABLE
IN FOUR CONFIGURATION
1. Wrap around
2. Interproximal
3. Single tooth wide
4. Single tooth narrow
 OBJECTIVES OF AN IDEAL
BARRIER MEMBRANE

1. It should be bio compatible &/or allow tissue

integration.
2. It should be non toxic & non carcinogenic.
3. It should be chemically inert & non antigenic.
4. It should be easily sterlizable.
5. It should be easy to handle during surgery.
6. It should be sufficiently rigid so as to
maintain a space b/w it & the root surface.
7. It should be supplied in different in
different design to suit the specific clinic
situation.
8. It should be easily stored & should have a
long shelf life.
9. It should be easily retrierable in case of
complication.
10. It should not be too expensive.
 INDICATIONS
1. Class II furcation
2. Infra bony defect.
3. Recession defect
4. To restore PD attachement in narrow 2
or 3 walled infra bony defect.
5. Alveolar ridge augmentation
6. Repair of apicocetomy defect.
CONTRAINDICATION

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.
 DEFECT SELECTION

• It may have the greatest impact on the

predictability of the regenerative regions.

A). MOST PREDICTABLE:-

1. for grade II furcation on teeth with high
interproximal bone.
2. 2 to 3 wall intra bony vertical defect >4-5 mm.
measurable defect.
B). MODERATE PREDICTABILITY:-
PREDICTABILITY
1. 2 wall defect.
2. Maxillary mesial or distal ClassII furcations.

C). LOW PREDICTABILITY:-

1. Class III furcation with high interproximal
bone.

D). LEAST PREDICTABLE:-

1. Horizontal bone loss.
2. Class III furcation with horizontal bone loss
SURGICAL PROCEDURE
Incisions
Defect preparation
Placement of suitable
memb.
Suturing
Material removal
 PRIMARY INCISIONS
1. Intra sulcular incisions are made in
preparation for a full mucoperiosteal flap.
2. All residual pocket epithelium is removed
after flap reflection to permit integration
b/w the e-PTFE & flap connective tissue.
3. Incision should extend 1-2 teeth mesial &/
or distal of the area being treated to permit
adequate visualization.
4. Vertical incision should be placed mesially
where necessary.
DEFECT PREPARATION
1. Degranulation of defect.
2. Scaling & root planning for removal of all
tooth deposits.
3. Decortification of bone for increased
vascularity & scratching of the PDL to
stimulate cell & vascular proliferation.
SELECTION & PLACEMENT OF
GORE-TEX PERIODONTAL
MATERIAL

1. Maintain sterility of material.

2. Choose a size that offers the most
ideal design for defect coverage.
3. Shape the material with scissors,
avoid leaving sharp edges.
4. Enough material should be left to permit lateral &
interproximal suturing while leaving at least 3 mm
apical & lateral overextension of defect margins.

5. Do not remove the open microstructure or coronal

portion of the material. It can be trimmed on the
lateral aspect.

6. The material should fit smoothly, avoiding folds,

overlaps & protrusions which may compromise the
overlying gingival tissue.
 SUTURE MATERIAL

1. Gore-Tex suture (provided with material) is

recommended for placing the material & flap
closure.

2. Silk or monofilament suture may be used in

areas away from the material.

3. Bioabsorbable sutures are not recommended.

SUTURING TECHNIQUES
1. Sling suture are used to approximate material over
the defect without engaging the flap or tissue.
2. The material must fit tightly against the tooth
surface at all points to prevent epithelial
proliferation b/w tooth & material & to help in
stabilizing the wound.
3. The flap margin should ideally be 2 to 3 mm
coronal to the material.

4. Tight flap apposition is desired to avoid

premature flap opening & material exposure.
 MATERIAL REMOVAL

1. Removal should
be 4 to 8 wks
after placement
or any time a
serious
complication
occurs.
2. If the material can not be removed with
a gentle tug, sharp dissection is
recommended.
3. Extreme care should be used to avoid damaging
the underlying the new granulation tissue.

4. A small tissue forcep is used to remove the

material.

5. The flap is re-approximated over the new tissue

& sutured with silk suture.
POST OPERATIVE
CONSIDERATIONS
1. Peridox mouth wash should be for 10 days if the
material becomes exposed, peridox should be used
untill removal.

2. Antibiotic coverage- (7-10 days)

Tetracycline 250mg q.i.d.
Doxycycline 100mg b.i.d.

3. Use of periodontal dressing is optional.

4. Flossing at the treatment site is to be avoided

while the material is in place.
5. The patient should be seen biweekly if there is
no exposure, & wkly if exposure is present.

6. Do not attempt to cover the previously

exposed material.

7. The material should be removed immediately if

any complication develops.
A FINAL WORD

• GUIDE TISSUE REGENERATION as a

procedure attempt regeneration through
differential tissue responses. It concluded
that GTR was not an experimental procedure &
that it showed predictability for connective
tissue attachment in infra bony defect & in
grade II furcation involvement.
REFERENCES
• Jan Lindhe – Clinic Periodontology & Implant
Dentistry, Fourth Edition.
• Carranza’s Clinic Periodontology, Ninth
Edition.
• Edward S. Cohen –Atlas of Cosmetic &
Reconstructive Periodontal Surgery, second
Edition.
• J D Manson & B M Eley – Outline of
Periodontics, Fourth Edition.
• Guru Raja Rao – Text Book Of Periodontology,
Second Edition.