The Technique Revisited - Guiding Tissue the Ominous Way

Varun Dahiya*, Gaurav Malhotra**, Pradeep Shukla***, Nitika Poonia****

Abstract
Untreated periodontal disease leads to tooth loss through destruction of the attachment apparatus and tooth supporting structures. The goals of periodontal therapy include not only the arrest of periodontal disease progression, but also the regeneration of structures lost to disease where appropriate. Conventional surgical approaches i.e. flap debridement continue to offer time tested and reliable methods to access root surfaces, reduce periodontal pockets, and attain improved periodontal form. However, these techniques offer only limited potential towards recovering tissues destroyed during earlier disease phases. Recently, surgical procedures aimed at greater and more predictable regeneration of periodontal tissues and functional attachment close to their original level have been developed, analyzed and employed in clinical practice. Key Words : Guided tissue regeneration, Periodontal disease, Surgical flaps.

INTRODUCTION

egeneration means that tissues which have become lost due to disease must be restored so that they have the same function and the same architecture as they had before disease initiation. 1 Regeneration following periodontitis first involves the re-establishment of a new cementum layer on the detached root surface, and preferably also the alveolar bone, to reduce tooth mobility. Whether or not regeneration is achieved will depend on the types of cells which repopulate the detached root surface first.1 Studies in the early 1970s indicated that the progenitor cells for cementum formation resided only in the PDL.

PRINCIPLES OF GUIDED CELL POPULATION AND GUIDED TISSUE REGENERATION

GTR is a term used to define procedure wherein regeneration of lost periodontal structures (i.e., cementum, periodontal ligament (PDL), alveolar bone) is sought via selective cell and tissue repopulation of the periodontal wound. Barrier techniques, using materials such as expanded polytetrafluoroethylene (ePTFE), polyglactin, polylactic acid, and collagen are employed to exclude dental tissues with little or no regenerative capacity (i.e., gingival epithelium and corium) while permitting or encouraging wound repopulation by cells derived from tissues with known or suspected regenerative potential (PDL and alveolar bone). This approach is based on the concept that the type of periodontal tissue that forms on instrumented root surfaces after surgical treatment is determined by
*Reader; **Prof.; ***Principal, Prof. & Head; ****Senior Lecturer, Department of Periodontics and Implantology, D J College of Dental Sciences and Research, Modi Nagar, U.P. 584

the type and origin of cells that migrate and attach to the root during early wound healing.2,3 Indications and contraindications for barrier procedures Patient selection is an extremely important aspect in achieving success in GTR therapy. Favorable clinical results are most often observed in healthy, nonsmoking patients who demonstrate good plaque control and compliance with other oral hygiene recommendations. Specific defects or problems that demonstrate optimal regenerative healing after GTR therapy include narrow two walled or three wall infrabony defects with at least 4mm of attachment loss and a 4mm infrabony component, circumferential defects, and class II furcation defects accompanied by a medium to long root trunk.4-6 Other potential indications for GTR include augmentation of ridge defeiciencies, coverage of root recession, repair of apicoectomy defects, osseous fill around immediate implant placement sites, and repair of osseous defects associated with failing implants.

MATERIALS USED AS BARRIER DEVICES

a) Non Resorbable Membranes Results using ePTFE to treat intraosseous defects show substantial bone fill averaging approximately 3.0 to 5.0 mm either with or without augmentation with graft materials. However, results have been reported to vary depending on the type of defect treayed, with 3 wall defects responding best.7-9 b) Bioabsorbable Membranes Non resorbable membranes require a second surgical procedure with possible patient discomfort and membrane exposure, leading to bacterial colonization. These factors have led to the development and utilization
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of various absorbable membranes for GTR procedures. Evaluation of both polylactic acid 7 and collagen membranes have reported clinical improvements similar to those achieved with non-resorbable membranes. In most studies, degradable polymers of polyglactic acid(PLA), polyglycolic acid (PGA) or mixtures of both PLA and PGA have also shown comparable clinical results to other materials, including ePTFE. c) Other Materials A wide varities of other bioabsorbable materials have been used in GTR therapy. These include, but are not limited to, freeze dried dura mater allografts, oxidized cellulose, alkali cellulose and calcium sulfate. Mixed results have been reported when these materials were used in attempts to repair/regenerate periodontal defects.10-13

DESIGN CRITERIA FOR BARRIER DEVICES

The early publications representing the development phase of guided tissue regeneration focused more on the biological principle of guiding tissues rather than the influence of barriers used. The barriers used during this development phase of guided tissue regeneration were not produced for medical use, but were chosen because of their: a) Microporosity, which allowed for passage of liquid and nutritional products but not for cells. b) They could be sterilized (autoclaved). However, recent publications have discussed the importance of the design of biomaterials used for dentoalveolar regeneration. The design criterias for guided tissue regeneration devices have been proposed and discussed by Scantlebury, Gottlow and Hardwick et al. These criteria may be used for guided tissue regeneration and to design specific membranes for individual guided tissue regeneration applications. The design criterias are 1) Tissue Integration : In 1982, George Winter, had proposed that specific porosities ingrew with connective tissue and stopped or slowed the migration of epithelial tissues. He called this phenomenon contact inhibition. To test this theorem, he placed small silicone buttons made with skirts of porous ePTFE material in the gingiva of dogs. The result of his experiments led to the evolution of the first design criteria. Membranes need an organized open microstructure to encourage tissue integration, which should result in stabilization of wound and inhibition of epithelial migration. This stabilization of wound during early healing and inhibition of epithelial migration will result in increased connective tissue attachment. 2) Cell Separation : In 1982 , Dr. John Prichard began experiments to see if wrapping of porous ePTFE structures around teeth would keep epithelium out of healing periodontal defects. Results indicated that
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ePTFE membranes limited the migration of epithelium, stabilized the wound and kept epithelium out of the healing periodontal defect. Around the same time, Dr. Sture Nymam and co workers using paper fiters, were able to regenerate periodontal ligament attachment to teeth. These landmark studies led to the second design criteria: Membranes should separate cell types so that desired cells originating from periodontal ligament and bone could repopulate the defect area. Cell exclusion requires incorporation of structural elements within the barrier that support isolation of the overlying gingival flap from the maturing fibrin clot in the wound.14-18 The overall shape of the barrier and how it adapts to the defect site, will also affect its ability to isolate regenerating tissues. 3) Clinically Manageable : In June 1985, investigators in Europe and US began testing porous ePTFE clinically. The first membranes were difficult to cut, sutures sometimes pulled out or left large holes in the membranes and the removal of membranes was difficult because their porous structures were so well incorporated in the tissues. All these findings led to the third design criteria: Materials should be cut and shaped easily. They should hold sutures and in case of complications, should be removed easily. With these criteria in mind, W.L. Gore and associates, Inc,. in 1985 introduced two- part material: a) An open microstructure collar: which could be implanted subgingivally, ingrows with the connective tissue and limits epithelial migration. b) An occlusive portion: That would stabilize the wound area, separate cell types for guided tissue regeneration, give a strong structure to retain sutures, be easy to cut and shape with no sharp edges to perforate and, in the event of complication, allow the membranes to be easily removed. 4) Space Making : The barrier should provide adequate space for the regenerating alveolar bone, periodontal ligament and cementum. This criteria of space making becomes more critical in case of bone defects and it is seen that the healing bone follows the contours of the membrane like the contours of a mold. This criteria requires mechanical properties and structural features allowing barrier to withstand forces exerted by the overlying flaps or those transmitted through the flaps and prevent collapse of soft tissue and reduction of wound space. 5) Biocompatibility : Biocompatibility is the ability of a material to perform with an appropriate host response in a specific situation, which means that neither the material adversely affects the body nor the physiological tissue environment adversely and significantly affects the material.
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ePTFE is one of the most inert materials known and body can not react with it chemically, hence tissues accept it, while exhibiting a healthy tissue reaction reaction. Preoperative considerations All GTR procedures require the clinician to consider three factors preoperatively. First, there must be adequate gingiva to cover the barrier postoperatively. For example, if there is severe gingival recession on the buccal of a mandibular first molar and a shallow vestibule, it may not be possible to cover the barrier adequately.18,19 Barrier coverage, although not absolutely essential to success, is desirable. Second, cervical enamel projections must be removed, or reattachment by long junctional epithelium occurs rather than regeneration. Finally, one must consider surgical access for root planing, barrier placement, and oral hygiene. For instance, teeth that are in close proximity to one another may not have sufficient space for placement of an interproximal barrier. GTR Around Implant Over the past 15 years, the principles of Guided Tissue Regeneration has been successfully applied to increase the volume of the host bone at sites chosen for implant placement. The concept of bone regeneration employs same principles of specific tissue exclusion and space provision, but is not associated with the teeth.20 Hence the term Guided Bone Regeneration is used for this technique. Biological Basis of Guided Bone Regeneration The main limitation for the implant-supported is the presence of bony defects or deficiency of the residual ridge.21 Four methods have been described to increase the rate of bone formation and to augment the bone volume. a) Osteoinduction, by the use of appropriate growth factors. b) Osteoconduction, where a grafting material serves as a scaffold for new bone growth. c) Distraction Osteogenesis, by which a fracture is surgically induced and two fragments are then slowly pulled apart. d) Guided Bone Regeneration, which allows space maintained by barrier membranes to be filled with new bone.

systems. Most importantly, establishing a scientifically sound, evidence based rationale is critical to the ultimate success of regenerative therapies.

BIBILOGRAPHY
1. American Academy of Peridontology. Glossary of Periodontal Terms. Chicago: American Academy of Periodontolgy 2001. Melcher AH. On the repair potential of periodontal tissues. J Periodontol 1976; 47 : 256. Melcher AH. Repair of wounds in the periodontium of the rat:influence of periodontal ligament on osteogenesis. Arch Oral Biol 1970; 15 : 1183. Karring T, Nyman S, Lindhe J. Healing following implantation of periodontitis affected roots into bone tissue. J Clin Periodontol 1980; 7 : 96. Gher ME, Vernino AR. Root morphology clinical significance in the pathogenesis and treatment of periodontal disease. J Am Dent Assoc 1980; 101 : 627. Everett FG, Jump EB, Holder TD, et al. The intermediate bifurcational ridge: A study of the morphology of the bifurcation of the lower first molars. J Debnt Res 1958; 37 : 162. Garrett S, Polson AM, Stoller NH, et al. Comparison of a bioabsorbable GTR barrier to a non-absorbable barrier in treating human Class II furcation defects. A multicenter parallel design randomized single blind trial. J Periodontol 1997; 68 : 667-75. Scantlebury TV. 1982-1992: A decade of technology development for Guided Tissue Regeneration. J Periodontol 1993 ; 64 : 1129-37. Gottlow J, Nyman S, Laurell L. Clinical results of Guided Tissue Regeneration therapy using a biodegradable device. J Dent Res 1992; 71 : 298-305. Hardwick R, Hayens BK, Flynn L. Devices of Dentoalveolar Regeneration : An up to date Literature Review. J Periodontol 1995; 66 : 495-505. Wang HL, Macneil RL. Guided Tissue Regeneration Absorbable Barriers. Dental Clinics of North America 1998; 42: 503-41. Caffesse RG, Becker W. Principles and Technique of Guided Tissue Regeneration. Dental Clinics of North America 1991; 35: 479-94. Tatakis DN, Promsudhti A, Wikesjo UME. Devices for Periodontal Regeneration. P 2000 1999; 19 : 59-73. Harikumar H. Nandakumar K. Guided Tissue Regeneration Principles and Guided Tissue Regeneration devices. A Review. JISO 1999; 2 : 18-20. Krauser JT, Garg AK. Membrane barriers for Guided Tissue Regeneration. In Babbush CA. Dental Implants. The Art and Science. Saunders. 135-50. Becker W. Guided Tissue Regeneration for Periodontal Defects. In : Polson AM. Periodontal Regeneration. Quintessence. 3rd edition. 137-166 Scantlebury TV. 1982-1992: A decade of technology development for Guided Tissue Regeneration . J Periodontol 1993 ; 64 : 1129-37. Gottlow J, Nyman S, Laurell L. Clinical results of Guided Tissue Regeneration therapy using a biodegradable device. J Dent Res 1992; 71 : 298-305. Schenk RK, Buser D, Dahlin C. Healing pattern of bone regeneration in membrane protected defects. Int J Oral Maxillofacial 1994; 9 : 13-29. Vert M, Li S, Garreau H. New insight on the degradation of bioresorbable polymeric devices based on lactic and glycolic acid. Clin Mater 1992; 10 : 3-8. Ruccuzzo M, Lugo M, Corrente G. Comparative study of a bioresorbable and a non-bioresorbable membrane in the treatment of human buccal gingival recession. J Periodontol 1996; 67 : 7-14. JIDA, Vol. 4, No. 12, December 2010

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SUMMARY
The goals of periodontal therapy include the reduction or elimination of tissue inflammation induced by bacterial plaque and its by products, correction of defects or anatomical problems caused by the disease process, and regeneration of lost periodontal tissues as consequence of disease destruction. While continuing effort seek to further our understanding of periodontal regeneration biology, we can also expect developments in biologic and materials sciences, providing new guided tissue regenerative materials and delivery
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