Guided Tissue Regeneration

Deep intrabony defect (PPD > 6 mm). The base of the pocket is apical to the bone crest.
Open flap debridement.
A collagen barrier membrane is placed between the root surface and the gingiva.
Cells originating from the intact periodontal ligament is given time and space to repopulate the root surface.
Repositioning of the flap.
Complete resolution of the defect. New root cementum, periodontal ligament and alveolar bone has been formed.

In terms of clinical attachment level gain and probing pocket depth (PPD) reduction, a surgical approach has been proven beneficial for the treatment of deep periodontal intrabony pockets (PPD ≥ 6 mm) [1, 2, 3]. Guided tissue regeneration (GTR) aims to regenerate lost periodontal structures by shielding the slow-dividing periodontal ligament and bone-forming cells from fast-proliferating epithelium by means of a barrier membrane. Thus, cells originating from the intact periodontal ligament is given time and space to repopulate the root surface resulting in regeneration of all periodontal tissues, i.e. root cementum, periodontal ligament and alveolar bone. Depending on the defect morphology, bone grafting material may be used to support the raised flap (non-contained defect). Accordingly, the space under the membrane is filled with a particulate bone graft (allogenic, xenogeneic or alloplastic grafts). The graft acts as a scaffold for osteogenic cells, provides space for the regenerative process and prevents the collapse of the barrier membrane.

maxgraft® granules

cerabone®

collprotect® membrane

maxresorb®

GTR for the treatment of a deep three-dimensional intrabony defect using cerabone®, collprotect® membrane and Straumann® Emdogain® - Dr. T. Schwaar

Pre-operative OPG shows deep vertical intrabony defects on the distal aspects of teeth 13 and 14.

Regeneration of an intrabony defect using collpotect® membrane & cerabone® - Dr. R. Cosgarea & Prof. Dr. Dr. A. Sculean (2)

Intrabony defect treated using collprotect® membrane & cerabone® (2) - Cosgarea & Sculean

Baseline clinical situation.

Regeneration of an intrabony defect using collprotect® membrane & cerabone® - Dr. R. Cosgarea & Prof. Dr. Dr. A. Sculean (1)

Intrabony defect treated using collprotect® membrane & cerabone® (1) - Cosgarea & Sculean

Pre-surgical probing reveals a deep intrabony defect on the distal aspect of the upper canine.

Non-contained intrabony defect treated using cerabone®, collprotect® membrane and Straumann® Emdogain® - Dr. T. Schwaar (2)

Pre-operative radiograph.

Non-contained intrabony defect treated using cerabone®, collprotect® membrane and Straumann® Emdogain® - Dr. T. Schwaar (1)

Pre-operative radiograph. Intrabony defect on the mesial aspect of tooth 14.

Entire papilla preservation technique (EPP) for the regenerative treatment of a severely compromised central incisor - Dr. S. Aslan

EPP for the treatment of a deep intrabony defect

Initial X-ray presenting a very deep intrabony defect of tooth 21

Application of the bone graft material	Fill the ossous defect as completely as possible with the bone graft particles. Avoid too much compression of the bone graft when applied to the defect.
Rehydration of the collagen membrane	The collprotect® membrane and the Jason® membrane can be applied dry or rehydrated with sterile saline solution or patient blood. It may be of advantage to apply the membrane in dry condition. After rehydration in situ, the membrane can be folded over the defect, and thus can easily be repositioned if required.
Rehydration of the bone substitute particles	The bone substitute particles can be added dry or may be rehydrated in sterline saline solution or patient blood in order to facilitate the handling.

Videos

GTR with collprotect® membrane and cerabone® granules (Dr. R. Cosgarea & Prof. Dr. Dr. A. Sculean)

Periodontal intrabony defects can be predictably treated with a barrier membrane in the sense of GTR [4, 5]. Following flap elevation and granulation tissue removal, the root surfaces are cleaned and a membrane is placed between the gingiva and tooth to cover the defect area completely. To achieve primary wound closure, the flap is repositioned tension-free.

Collagen membranes are very widely used in GTR procedures due to inherent advantageous properties of collagen. Collagen exhibits an excellent biocompatibility and controlled, complete degradation together with a natural hemostatic activity and chemotactic attraction of fibroblasts and osteoblasts. For small bone defects like periodontal intrabony defects the collprotect® membrane with intermediate barrier function is the optimal choice. Of course, the pericardium membrane, Jason® membrane, which offers a significantly longer barrier function, may also be applied.

Non-contained intrabony defects (1- or 2-wall defects) usually require support of the soft tissue, thus different kind of bone grafts may be used. cerabone® is a natural bovine bone graft consisting of pure bone mineral. Due to its natural bone structure cerabone® provides optimal support for bone forming cells and blood vessels. A further alternative are the allogenic maxgraft® granules or the synthetic material maxresorb®. maxresorb® is a biphasic material composed of 60% hydroxyapatite and 40% beta-tricalcium phosphate. While the fast resorption of beta-TCP quickly offers space for new bone formation, the HA component provides volume stability for an extended time period.