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Guided tissue regeneration

Article  in  Journal of Oral Research and Review · January 2021

DOI: 10.4103/jorr.jorr_11_20

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Case Report

Guided tissue regeneration

Shreeprasad Vijay Wagle, Amit Arvind Agrawal, Dinaz Bardoliwala, Chhaya Patil
Department of Periodontology and Implantology, MGV’s KBH Dental College and Hospital, Nashik, Maharashtra, India

Abstract Regeneration is a reproduction or reconstruction of a lost or injured part in such a way that the architecture
and function of the lost or injured tissues are completely restored. Epithelium acts as a barrier to successful
therapy because its presence interferes with the direct apposition of connective tissue and cementum,
therefore would limit the height to which periodontal fibers can become inserted to cementum. Guided
tissue regeneration (GTR) describes procedures attempting to regenerate lost periodontal structures
through differential tissue responses and typically refers to regeneration of periodontal attachment.
Barrier techniques are used for excluding connective tissue and gingiva from the root in the belief that
they interfere with regeneration.

Keywords: Guided tissue regeneration, periodontitis, vertical bone defect

Address for correspondence: Dr. Shreeprasad Vijay Wagle, Department of Periodontology and Implantology, MGV’s KBH Dental College and Hospital,
Nashik, Maharashtra, India.
E‑mail: svw1593@gmail.com
Submitted: 14‑Apr‑2020 Revised: 20-Jun-2020 Accepted: 31-Jul-2020 Published: 15-Feb-2021

INTRODUCTION caused by the progression of periodontal disease. Over the

The regeneration or restitution of lost supporting tissue has
always been considered the ideal objective of periodontal
therapy. Regeneration can be defined as the reproduction
or reformation of organs or tissue that has been lost or
injured as a result of a wound or infection. Regenerative
periodontal procedure involves the creation of new
alveolar bone, cementum, and periodontal ligament. Most
periodontal practices focus on the prevention of disease,
initiation, and corrective surgical treatment to eliminate
deep pockets. Regeneration is distinct from tissue repair
and is characterized by replacement of the damaged tissues
with something that may be inferior to the original tissues,
both structurally and functionally.[1]
Eliminating bacteria and regenerating bone and supporting
tissues helps in reducing pocket depth and repair damage
last decade, different modalities of regenerative treatment
have been used and clinically applied. The positive effect
of bone grafts and bone substitute on the outcome of
periodontal regenerative procedures is well documented.[2]
Bone substitute should have the following properties such
as clinical effectiveness, functional periodontal repair,
apparent bone defect fill, and pocket reduction to
manageable levels.
Infrabony defects are a common clinical finding in
periodontal disease. Multiple treatment options are available
for treating infrabony defects[2]  –  (i) conventional flap
surgery, (ii) resective osseous surgery, (iii) regenerative
osseous surgery, (iv) bone grafts, (v) guided tissue
regeneration (GTR), and (vi) platelet‑rich plasma. GTR
in a combination of various grafts has shown promising
effect in improving clinical and radiographic parameters.

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DOI:
10.4103/jorr.jorr_11_20 How to cite this article: Wagle SV Agrawal AA, Bardoliwala D, Patil C.
Guided tissue regeneration. J Oral Res Rev 2021;13:46-9.

46 © 2021 Journal of Oral Research and Review | Published by Wolters Kluwer - Medknow
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Wagle, et al.: Guided tissue regeneration

The main objective of GTR is to regenerate the periodontal

tissues lost due to advanced stages of disease.[3] The
principle of GTR is allowing selective repopulation of
periodontal cells, especially fibroblasts, which helps in the
formation of new periodontal tissues.[4] In addition, the
membrane provides space for optimal wound stability that a b
is necessary for periodontal regeneration.[1] Figure 1:  (a) Preoperative probing depth.  (b) Preoperative
orthopantomogram showing vertical and horizontal bone loss
CASE REPORT

A 36‑year‑old  male patient reported with generalized

gingival bleeding and difficulty in chewing related with
mandibular right posterior teeth. The clinical presentation
included a reddish pink, swollen gingiva, with bleeding
on probing and clinical probing depth in the mandibular a b
right [Figure 1a] posterior quadrant recorded between Figure 2: Intraoperative and immediate postoperative views. (a) Bone
graft placed and collagen membrane applied,  (b) interrupted loop
6 and 9 mm, while in the remaining areas, it ranged suturing done using 3‑0 silk suture
between 3 and 5 mm. Horizontal defects were found
radiographically and a vertical defect was found with
respect to the mandibular right molars, Grade III furcation
involvement with 46 suggestive of generalized aggressive
periodontitis [Figure 1b]. Therapeutic scaling and root
planing (SRP) was performed, and curettage was done. The
management for the mandibular right posteriors further a b
included a conventional flap surgery with demineralized
freeze‑dried bone allograft  (DFDBA) bone graft and
collagen membrane placement for bone regeneration with
respect to tooth numbers 46 and 47 [Figure 2].

Procedure
A thorough Phase I therapy was done to reduce the
inflammation. Root canal treatment was performed 2
months prior to surgery. The patient was given antibiotics
and analgesics for 3 days (amoxicillin 500 mg thrice daily,
paracetamol and aceclofenac combination twice daily,
and pantoprazole 40 mg twice daily) and asked to report
after 1 week after SRP for surgery. Prior to surgery, again
the probing depth was measured. The pocket depth was
9 mm with tooth number 46 on the day of surgery. Local
anesthesia was achieved by buccal and lingual infiltration.
Lignocaine hydrochloride with adrenaline (1:80,000) was
used. Full‑thickness mucoperiosteal flap was elevated both
buccally and lingually. Granulation tissue was removed
using a curette (Hu‑Friedy, USA). Calculus deposits were
removed with ultrasonic scaling. The inflamed inner wall of
the flap was trimmed using Castro‑Viejo scissors [Figure 3].
DFDBA bone graft was mixed with saline to a packable
consistency. The bone graft was packed into the site in
increments using a condenser. The bone graft was filled
adequately and condensed. Care was taken to avoid
overfilling the defect. The collagen membrane was cut
Journal of Oral Research and Review | Volume 13 | Issue 1 | January-June 2021 47
c d
Figure 3: Pre‑and intra‑operative photographs of surgical site. (a) Probing
depth, (b) combined osseous defect and furcation involvement seen
after periodontal flap reflection and debridement, (c) vertical bone defect
measurement at distobuccal line angle with 46, (d) vertical bone defect
measurement at mesiobuccal line angle with 46
according to the size of the defect. The membrane was then
inserted into the defect and presuturing was done before
complete placement of the membrane. The membrane
was inserted totally into the defect and the final knot was
placed [Figure 2].
Suture removal was done after 1 week. The patient did
not develop any postoperative complications. The wound
healing was satisfactory after 1 week of surgery. Saline
irrigation was done to remove soft deposits and sutures
were removed. The patient was recalled after every 3
months, and then clinical parameters were assessed
clinically as well as radiographically. The probing depth
was not assessed in order to avoid any injury to the healing
tissues. Intraoral periapical radiograph after 6 months
showed an appreciable increase in bone level and bone
fill [Figure 4].
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Wagle, et al.: Guided tissue regeneration
a b
Figure 4:  (a) Intraoral periapical radiographs before periodontal
therapy,  (b) intraoral periapical radiographs after 6 months of
regenerative periodontal therapy showing bone fill in defect with tooth
number 46
DISCUSSION
A prominent clinical finding in advanced periodontal
disease cases is infrabony defects. Numerous regenerative
techniques have been developed to treat such defects
with varying clinical results. GTR in combination with
bone graft stands as a successful treatment modality in
periodontal regenerative surgeries.[5] GTR is found to be
more effective when compared with conventional surgery
in the gain of clinical attachment, reduction in probing
depth, and in the treatment of intrabony and furcation
defects.[6]
DFDBA was used as a bone graft substitute in this case. The
principal reason behind demineralizing is based on studies
by Urist et al.,[6] who suggested that the demineralization
of lyophilized bone would allow the exposure of
morphogenetic bone proteins and polypeptides that induce
the pluripotential stem cells to differentiate into osteoblasts.
However, it has been found that this osteoinductive
capacity depends on the donor characteristics, especially
the age, and the degree of demineralization, in such a way
that depending on the bone bank and even the batch, the
capacity to induce bone formation can vary and may even
be nonexistent.
Numerous studies support the use of the bone graft
material and the collagen membrane used in this case.
The bone graft occupies the infrabony defect as a filler
material.[7,8] It helps in supporting the GTR membrane by
preventing the collapse. It acts as a substitute for the lost
bone and facilitates native bone formation. This process
of formation of native bone is done by osteoconductive/
osteoinductive activity.[9] It enhances the process of
healing following surgery. It serves as a framework to the
bone‑forming cells and blood vessels, thereby encouraging
formation of healthy new bone and also helping in the
repair of the osseous defect.
Collagen membrane is a bio‑absorbable membrane.
It undergoes resorption by getting incorporated into
the connective tissues or by undergoing degradation
48 Journal of Oral Research and Review | Volume 13 | Issue 1 | January-June 2021
by macrophages. This process takes about 6–8 weeks
to complete. Even though they undergo resorption,
their function in acting as a barrier is as effective as a
nonresorbable membrane.[8]
The collagen membrane acts as a scaffold upon which
the fibroblasts migrate and undergo proliferation to
form the periodontal ligament fiber cells. The Type I
collagen contained in membrane also has hemostatic
property. This property enables the membrane to accelerate
the wound healing in the surgical site, thereby yielding
faster results.[10,11]
In the present study, after 3 months of surgery, probing
pocket depth was reduced to 4 mm and the clinical
attachment loss was reduced from 9 to 5 mm distal to 36.
The bone fill of about 4 mm was observed in the intrabony
defect with 36 [Figure 4].
CONCLUSION
The results of this case study indicate that the use of
GTR technique (collagen membrane) in combination
with DFDBA bone graft material was beneficial for
the treatment of periodontal intrabony defects. This
combination technique provided improved outcomes in
terms of clinical and radiographic parameters.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient(s) has/have
given his/her/their consent for his/her/their images and
other clinical information to be reported in the journal.
The patients understand that their names and initials will
not be published and due efforts will be made to conceal
their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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