Flap reflection

Note: Severe vertical bone loss in the facial of #7 and #8 and a periapical cyst on #9 (upper left central incisor).

Placement of Biogran (synthetic bone graft)

What is guided tissue regeneration?
Guided tissue regeneration is the term refer to the concept of using barriers of different types in periodontal surgery to promote regeneration of attachment apparatus of the tooth, i.e. alveolar bone, cementum, and periodontal limament. The barrier is constructed of biocompatible material, exhibits occlusive properties to prevent fibrous connective tissue invasion of the space, provides some degree of protection from bacterial invasion should the membrane become exposed to the oral environment, provides suitable space which osseous regeneration can occur, and finally, is capable of tissue integration to help stabilize the healing wound, creating a seal between bone and material to prevent connective tissue leakage into the defect, and retards the migration of epithelium around the material.

Noted that regeneration is different from repair, as achieved in scaling and root planing in treatment of periodontitis. Repair represents the invasion of connective tissue into the defect space, and result in the establishment of long junctional epithelium. Attachment is a type of connective tissue attachment.

What is required for a successful guided tissue regeneration surgery?

The prognosis for guided tissue regenerative surgery is very good. As with any treatment, the local and systemic etiology must be identified. It is not as important that how extensive is the defect but what cause the defect to occur. Identify the cause of the periodontal lesion is the key for preventing the recurrence of the defect after the surgery has been deemed successful. The key to achieve predictable results are:

• Use of an appropriate barrier membrane. Membrane selection should be base on biocompatibility, ease of adaptation to the defect, tissue integration, creation of space for bone regeneration, and bioavailability during the crucial regenerative period.
• Surgical technique in flap reflection, debridement of defect, and adaptation.
• The use of bone graft with osteoinductive and osteoconductive property to further stimulation of migration, differentiation, and maturation of new bone.
• Stabilization and close adaptaion of membrane to the surrounding bone can be aided with bone screw or tack (resorbable or nonresorbable)
• Primary flap closure
• Eliminate of all the systemic and local etiology which may lead to surgical complication (autoimmune disease, diabetes, occlusal trauma, poor oral hygiene)
• The use of adjunctive therapy postoperatively such as periostat may help in regeneration result.

If we control all the factors above, the outcome should be very successful in regeneration of new attachment apparatus.

On the right hand column is an example of a case using guided tissue regeneration to treat the severe bone loss in the maxillary anterior region. Patient was diagnosed of localized severe periodontitis in the maxillary anterior region. Occlusal trauma, poor oral hygiene are the etiology. Patient treatment included scaling and root planing, followed by guided tissue regeneration. Tooth #9 (upper left central incisor) is treated with root canal therapy. Finally, Orthodontic therapy is used to eliminate occlusal trauma due to anterior crowding (upper right canine, lateral, and premolar pushed together).

For full presentation of this case done in Flash, please browse our porfolio section, under "Treatmet of Furcation Involvement using Guided Tissue Regeneration"