Guided tissue regeneration (GTR) uses membranes placed over bone defects to separate gingival tissues from the root surface during healing. This favors regeneration of periodontal ligament and bone rather than just epithelial migration. Initial animal studies and some human studies found GTR resulted in new cementum, bone, and periodontal ligament attachment. Early non-resorbable membranes required a second surgery for removal, so resorbable membranes were developed. Autogenous periosteum has also been explored as a potential resorbable membrane and stimulator of periodontal regeneration.
Guided tissue regeneration (GTR) uses membranes placed over bone defects to separate gingival tissues from the root surface during healing. This favors regeneration of periodontal ligament and bone rather than just epithelial migration. Initial animal studies and some human studies found GTR resulted in new cementum, bone, and periodontal ligament attachment. Early non-resorbable membranes required a second surgery for removal, so resorbable membranes were developed. Autogenous periosteum has also been explored as a potential resorbable membrane and stimulator of periodontal regeneration.
Guided tissue regeneration (GTR) uses membranes placed over bone defects to separate gingival tissues from the root surface during healing. This favors regeneration of periodontal ligament and bone rather than just epithelial migration. Initial animal studies and some human studies found GTR resulted in new cementum, bone, and periodontal ligament attachment. Early non-resorbable membranes required a second surgery for removal, so resorbable membranes were developed. Autogenous periosteum has also been explored as a potential resorbable membrane and stimulator of periodontal regeneration.
The methode of the prevention of epithelia migration
along the cementa wall of the pocket and maintaining space for clot stabilization is a technic called guide tissue regeneration. This methode is derived from the classic studies of Nyman, Lindhe, Karring, and Gottlow an is based on the assumption only the periodontal ligament cells have the potential for regeneration of the attachment apparatus of the tooth. GTR consists of placing barriers of different types (membranes) to cover the bone and periodontal ligament. Thus temporarily separating them from gingival epithelium and the gingival connective tissue from the root surface during the postsurgical healing phase not only prevents the epithelial migration into the wound but also favors repopulation of the area by cells from the periodontal ligament and the bone.
Initial animal experiments using millipore filters and teflon membranes resulted in regiont of cementum and alveolar bone and a functional periodontal ligament. Clinnical case reports presented GTR result in a gain in attachment level that is not necessarily associated with a build up of alveolar bone. Histologic studies in human provided evidence of periodontal reconstruction in most cases, even with horizontal bone loss.
The use of polytetrafluoroethylene (PTFE) membranes has been tested in controlled clinical studies in mandibular molar furcations and has shown statistically significant decreases in pockett depths and improvement in attachement levels after 6t months, but bone meassurments have been inconclusive. A study on maxillary molar furcations did not result in significant gain in attachment or bone levels. The initial membranes deeloped were nonresorbable and the required a second surgical procedure to remove them. The second procedure was accomplished after the initial stages of healing. Ussualy 3 to 6 weeks after the first intervention. The second procedure was a significant obstacle in the utilization of the GTR technique, therefore the resorbable membranes dere developed.
The ePTFE membrane (nonresorbable) can be obtained in drfferent shapes and sizes to suit proximal spaces anf facial/lingual surfaces of furcations. The technique for its use is as follows. 1. Raise a mucoperiosteal flap with vertical incisions, extending a minimum of two teeth anteriorly and one tooth distallt to the tooth being treated 2. Debride the osseous defect and throughly plane the roots. 3. Trim the membrane to the approximate size of the area being treated. The apical border of the material should extend 3 to 4 mm apical to the margin of the efect and laterally 2 to 3 mm beyond the defect. The occlusal border of the membrane should be placed 2 mm apical to the cementoenamel junction. 4. Suture the membrane tightly around the tooth with sling suture. 5. Suture the flap back in its original position or slightly coronal to it, using independent sutures interdentally an in vertical incisions. The flap should cover the membrane completely. 6. The use of periodontal dressings is optional, and the patient is placed on antibiotic therapy for 1 week.
After 4 to 6 weeks, the margin of the membrane may become exposed. The membrane is remove carefully, minimizing trauma to the underlying tissue. If it cannot be removed easily, the tissue are anesthetized, and the material is surgically removed using a small flap. The result obtained with the GTR technique are enchanced when the technique is combined with grafts placed in the defects (see the section on combined techniques)
Biodegradable membrans. The search for resorbable membranes has included trials and teset with numerons materials and collagens from different species such as bovine, porcine, polylactic acid, vicryl, biobrane and freeze dried dura mater. Clinical studies of the mixture of co-polymers membranes (guidor membrane, no longer on the market) and a poly-Dlactide co glycolide (resolut membrane, also no longer on the market) have shown significant gains in clinical attachment and bone fill.
Resorbable membranes marketed in the united states include oseoquest (gore), a combination of polyglicolic acid, polylactic acid, and trimethylene carbonate that resorbs at 6 to 14 months; BioGuide (osteohealth), a bilayer porcine-denved collagen; Atrisorb (block drug), a polylactic acid gel, and BioMend (calcitech), a bovine achilles tendon collagen that resorb in 4 to 18 weeks. Of these, BioGuide is the most resorbable membrane. The use of membranes is ussually combined with autogenous bone from adjacent areas or other graft materials and root biomodifiers. These combined techniques are discussed at the end of this chapter. The potential of using autogenous periosteum as a membrane and also to stimulate periodontal regeneration has been explored in two controlled clinical studies, one of grades II furcation involvements in mandibular molars and another of interdental defects. The periosteum was obtained from the patients palate by means of a window flap. Both studies reported that autogenous periosteal grafts can be used in GTR and result in significant gains in clinical attachment and osseous defect fill.