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Guided tissue 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.

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