Guided bone and tissue regeneration (dentistry)

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Guided bone and tissue regeneration
MeSH D048091

Guided bone regeneration (GBR) and guided tissue regeneration (GTR) are dental surgical procedures that use barrier membranes to direct the growth of new bone and gingival tissue at sites with insufficient volumes or dimensions of bone or gingiva for proper function, esthetics or prosthetic restoration. Guided bone regeneration typically refers to ridge augmentation or bone regenerative procedures; guided tissue regeneration typically refers to regeneration of periodontal attachment. [1]

Contents

Guided bone regeneration is similar to guided tissue regeneration, but is focused on development of hard tissues in addition to the soft tissues of the periodontal attachment. At present, guided bone regeneration is predominantly applied in the oral cavity to support new hard tissue growth on an alveolar ridge to allow stable placement of dental implants. When bone grafting is used in conjunction with sound surgical technique, guided bone regeneration is a reliable and validated procedure.

History

Use of barrier membranes to direct bone regeneration was first described in the context of orthopaedic research 1959. [2] The theoretical principles basic to guided tissue regeneration were developed by Melcher in 1976, who outlined the necessity of excluding unwanted cell lines from healing sites to allow growth of desired tissues. [3] Based on positive clinical results of regeneration in periodontology research in the 1980s, research began to focus on the potential for re-building alveolar bone defects using guided bone regeneration. The theory of Guided tissue regeneration has been challenged in dentistry. The GBR principle was first examined by Dahlin et al. in 1988 on rats. The selective ingrowth of bone-forming cells into a bone defect region could be improved if the adjacent tissue is kept away with a membrane; this was confirmed in a study by Kostopoulos and Karring in 1994. GBR can be used for bone regeneration on exposed implant coils . [4]

Overview

Four stages are used to successfully regenerate bone and other tissues, abbreviated with the acronym PASS: [5]

  1. Primary closure of the wound to promote undisturbed and uninterrupted healing
  2. Angiogenesis to provide necessary blood supply and undifferentiated mesenchymal cells
  3. Space creation and maintenance to facilitate space for bone in-growth
  4. Stability of the wound to induce blood clot formation and allow uneventful healing

After tooth removal, it takes 40 days for the normal healing process to take place (clot formation to socket filled with bone, connective tissue and epithelium). [6]

Application

The first application of barrier membranes in the mouth occurred in 1982 [7] [8] [9] in the context of regeneration of periodontal tissues via GTR, as an alternative to resective surgical procedures to reduce pocket depths. [5] [10] A barrier membrane is utilized in the GBR technique to cover the bone defect and create a secluded space, which prevents the connective tissue from growing into the space and facilitates the growth priority of bone tissue. An added benefit of the membrane is that it provides protection of the wound from mechanical disruption and salivary contamination. [6]

Barrier membrane criteria should be as follows:

Several surgical techniques via GBR have been proposed regarding the tri-dimensional bone reconstruction of the severely resorbed maxilla, using different types of bone substitutes that have regenerative, osseoinductive or osseoconductive properties which is then packed into the bony defect and covered by resorbable membranes. In cases where augmentation materials used are autografts (tissue transfer from same person [12] ) or allografts (tissue from genetically dissimilar members of same species [12] ) the bone density is quite low and resorption of the grafted site in these cases can reach up to 30% of original volume. Other materials available xenografts (tissue donor from another species [12] ) and autogenous bone. [6] For higher predictability, nonresorbable titanium-reinforced d-polytetrafluoroethylene (d-PTFE) membranes—as a barrier against the migration of epithelial cells within the grafted site—are recommended. In patients with systemic problems interdisciplinary collaboration is indicated to adjust therapy background so that it does not adversely affect implanto-prosthetic treatment. [13] Current treatments for destructive periodontal disease are not able to restore damaged bone and connective tissue support for teeth (infra-bony defects).[ citation needed ]

Currently there are two types of barrier membranes available: resorbable and non-resorbable. [6]

Non-resorbable membranes:

The main types of non-resorbable barrier membranes are expanded polytetrafluoroethylene (e-PTFE), high-density polytetrafluoroethylene (d-PTFE), titanium mesh and titanium-reinforced PTFE. [6]

Expanded polytetrafluoroethylene (e-PTFE) became the most common non-resorbable membrane used for bone regeneration in the 1990s. Gore-Tex was the most popular type of e-PTFE. [14] The e-PTFE membrane is sintered with pores of 5 - 20 μm within the framework of the material. The e-PTFE membrane behaves as a barrier to prevent fibroblasts and various connective-tissue cells from entering the bone defect in order to allow the slower moving cells that are osteogenic to repopulate the defect. [15] A study used e-PTFE membranes to cover surgically constructed average size bone defects in the mandibular angles of rats. Consequently, the e-PTFE membrane acted as a barrier to soft tissue and sped up bone healing, which took place between 3–6 weeks while no healing occurred in the non-membrane control group during a 22 week period. [16]

The biological method of osteopromotion by exclusion is good for predicting ridge growth or defect regeneration. [17]

Resorbable membranes:

There are many different types of resorbable membranes out there but the main ones are synthetic polymers and natural biomaterials. Synthetic polymers are such that it is a polylactic acid bilayer, or the collagen-derived membranes. These membranes can be obtained from bovine or porcine or dermis. E.g. Emdogain which has been shown to significantly improve probing attachment levels (1.1mm) and periodontal pocket depth reduction (0.9mm) when compared to a placebo or control materials. [18] Resorption rates ranging from six to 24 weeks depending on its different chemical structures. With the resorbable membrane used, the membrane will bio-degrade. There is no need for a second surgery to remove the membrane, this will prevent any disruption to the healing process of the regenerated tissues. [11] A synthetic resorbable membrane (eg: Powerbone Barrier Membrane) is an ideal alternative to the resorbable collagen material. Randomised clinical trials compared the stability of augmented bone between a synthetic resorbable membrane and a collagen membrane with guided bone regeneration simultaneous to dental implant placement in the aesthetic zone in terms of facial bone thickness. [19]

Success depends on several factors: osteoblasts being present at the site, a sufficient blood supply, stabilisation of the graft during healing, and soft tissue not being under tension. [12]

Indications

There are several uses of bone regeneration:

Contraindications

Contraindications include: [20]

Potential complications

Potential complications include: [20]

See also

Related Research Articles

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Osseointegration is the direct structural and functional connection between living bone and the surface of a load-bearing artificial implant. A more recent definition defines osseointegration as "functional ankylosis ", where new bone is laid down directly on the implant surface and the implant exhibits mechanical stability. Osseointegration has enhanced the science of medical bone and joint replacement techniques as well as dental implants and improving prosthetics for amputees.

Periodontology or periodontics is the specialty of dentistry that studies supporting structures of teeth, as well as diseases and conditions that affect them. The supporting tissues are known as the periodontium, which includes the gingiva (gums), alveolar bone, cementum, and the periodontal ligament. A periodontist is a dentist that specializes in the prevention, diagnosis and treatment of periodontal disease and in the placement of dental implants.

<span class="mw-page-title-main">Sinus lift</span> Surgery to restore bone for tooth implants

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“Lateral periodontal cysts (LPCs) are defined as non-keratinised and non-inflammatory developmental cysts located adjacent or lateral to the root of a vital tooth.” LPCs are a rare form of jaw cysts, with the same histopathological characteristics as gingival cysts of adults (GCA). Hence LPCs are regarded as the intraosseous form of the extraosseous GCA. They are commonly found along the lateral periodontium or within the bone between the roots of vital teeth, around mandibular canines and premolars. Standish and Shafer reported the first well-documented case of LPCs in 1958, followed by Holder and Kunkel in the same year although it was called a periodontal cyst. Since then, there has been more than 270 well-documented cases of LPCs in literature.

<span class="mw-page-title-main">Crown lengthening</span> Dental procedure

Crown lengthening is a surgical procedure performed by a dentist, or more frequently a periodontist, where more tooth is exposed by removing some of the gingival margin (gum) and supporting bone. Crown lengthening can also be achieved orthodontically by extruding the tooth.

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<span class="mw-page-title-main">Subepithelial connective tissue graft</span>

In dentistry, the subepithelial connective tissue graft is an oral and maxillofacial surgical procedure first described by Alan Edel in 1974. Currently, it is generally used to obtain root coverage following gingival recession, which was a later development by Burt Langer in the early 1980s.

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<span class="mw-page-title-main">Furcation defect</span>

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  2. Generalized aggressive periodontitis (GAP)
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<span class="mw-page-title-main">Gingival grafting</span>

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References

  1. ↑ Larsen P, Ghali GE (2004). Peterson's Principals of Oral and Maxillofacial Surgery. Hamilton, Ont: B.C. Decker. ISBN   978-1-55009-234-9.[ page needed ]
  2. ↑ Hurley LA, Stinchfield FE, Bassett AL, Lyon WH (October 1959). "The role of soft tissues in osteogenesis. An experimental study of canine spine fusions". The Journal of Bone and Joint Surgery. American Volume. 41-A: 1243–54. doi:10.2106/00004623-195941070-00007. PMID   13852565.
  3. ↑ Melcher AH (May 1976). "On the repair potential of periodontal tissues". Journal of Periodontology. 47 (5): 256–60. doi:10.1902/jop.1976.47.5.256. PMID   775048.
  4. ↑ Mützel W, Tillmann K, Gerhards E (February 1979). "[Time of persistence of fluocortolone hexanoate in the knee-joint after intra-articular injection (author's transl)]". Deutsche Medizinische Wochenschrift. 104 (8): 293–5. doi:10.1055/s-0028-1103897. PMID   761531.
  5. 1 2 Wang HL, Boyapati L (March 2006). ""PASS" principles for predictable bone regeneration". Implant Dentistry. 15 (1): 8–17. doi:10.1097/01.id.0000204762.39826.0f. PMID   16569956. S2CID   3548845.
  6. 1 2 3 4 5 Liu J, Kerns DG (May 2014). "Mechanisms of guided bone regeneration: a review". The Open Dentistry Journal. 8: 56–65. doi: 10.2174/1874210601408010056 . PMC   4040931 . PMID   24894890.
  7. ↑ Nyman S, Lindhe J, Karring T, Rylander H (July 1982). "New attachment following surgical treatment of human periodontal disease". Journal of Clinical Periodontology. 9 (4): 290–6. doi:10.1111/j.1600-051X.1982.tb02095.x. PMID   6964676.
  8. ↑ Gottlow J, Nyman S, Karring T, Lindhe J (September 1984). "New attachment formation as the result of controlled tissue regeneration". Journal of Clinical Periodontology. 11 (8): 494–503. doi:10.1111/j.1600-051X.1984.tb00901.x. PMID   6384274.
  9. ↑ Gottlow J, Nyman S, Lindhe J, Karring T, Wennström J (July 1986). "New attachment formation in the human periodontium by guided tissue regeneration. Case reports". Journal of Clinical Periodontology. 13 (6): 604–16. doi:10.1111/j.1600-051X.1986.tb00854.x. PMID   3462208.
  10. ↑ Klokkevold PR, Newman MC, Takei HH (2006). Carranza's Clinical Periodontology. Philadelphia: Saunders. ISBN   978-1-4160-2400-2.[ page needed ]
  11. 1 2 Clinical periodontology and implant dentistry. Lindhe, Jan., Lang, Niklaus Peter., Karring, Thorkild. (5th ed.). Oxford: Blackwell Munksgaard. 2008. ISBN   978-1405160995. OCLC   171258234.{{cite book}}: CS1 maint: others (link)
  12. 1 2 3 4 5 Goldstep, Fay (9 December 2015). "Bone Grafts For Implant Dentistry: The Basics". Oral Health Group. Retrieved 2019-01-29.
  13. ↑ Barbu H, Comăneanu M, Bucur M (Mar 2012). "Guided Bone Regeneration in severely resorbed maxilla". Rev. chir. oro-maxilo-fac. implantol. (in Romanian). 3 (1): 24–29. ISSN   2069-3850. 61. Retrieved 2012-08-30.(webpage has a translation button)
  14. ↑ Dahlin, Christer; Gottlow, Jan; Linde, Anders; Nyman, Sture (January 1990). "Healing of Maxillary and Mandibular Bone Defects Using a Membrane Technique: An Experimental Study in Monkeys". Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery. 24 (1): 13–19. doi:10.3109/02844319009004514. ISSN   0284-4311. PMID   2389116.
  15. ↑ Liu, Jie; Kerns, David G (2014-05-16). "Mechanisms of Guided Bone Regeneration: A Review". The Open Dentistry Journal. 8 (Suppl 1): 56–65. doi: 10.2174/1874210601408010056 . ISSN   1874-2106. PMC   4040931 . PMID   24894890.
  16. ↑ Dahlin, C; Linde, A; Gottlow, J; Nyman, S (May 1988). "Healing of bone defects by guided tissue regeneration". Plastic and Reconstructive Surgery. 81 (5): 672–676. doi:10.1097/00006534-198805000-00004. PMID   3362985. S2CID   8014548.
  17. ↑ Buser, D.; Brägger, U.; Lang, N. P.; Nyman, S. (1990). "Regeneration and enlargement of jaw bone using guided tissue regeneration". Clinical Oral Implants Research. 1 (1): 22–32. doi:10.1034/j.1600-0501.1990.010104.x. ISSN   1600-0501. PMID   2099209.
  18. ↑ Esposito M, Grusovin MG, Papanikolaou N, Coulthard P, Worthington HV (October 2009). "Enamel matrix derivative (Emdogain(R)) for periodontal tissue regeneration in intrabony defects". The Cochrane Database of Systematic Reviews (4): CD003875. doi:10.1002/14651858.cd003875.pub3. PMC   6786880 . PMID   19821315.
  19. ↑ Arunjaroensuk S, Panmekiate S, Pimkhaokham A (2017-10-13). "The Stability of Augmented Bone Between Two Different Membranes Used for Guided Bone Regeneration Simultaneous with Dental Implant Placement in the Esthetic Zone". The International Journal of Oral & Maxillofacial Implants. 33 (1): 206–216. doi:10.11607/jomi.5492. PMID   29028848.
  20. 1 2 Bateman G, Saha S, Chapple IL (2007). Contemporary periodontal surgery: an illustrated guide to the art behind the science. London: Quintessence. ISBN   9781850971238.
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